Perfectionism and psychopathology: a review of research and treatment

Is perfectionism related to pre-existing and future insomnia? A prospective study

OBJECTIVE

The purpose of this study was to examine the role of perfectionism to pre-existing and future insomnia.

METHODS

Based on a random sample from the general population (N=3600), 1936 participants filled out a baseline and 1-year follow-up survey on perfectionism (concern over mistakes and personal standards), emotional distress and insomnia.

RESULTS

The results from sequential logistic regression analyses showed that concern over mistakes was significantly related to pre-existing and future insomnia. When emotional distress was accounted for, none of the perfectionism subscales contributed significantly in explaining pre-existing and future insomnia.

CONCLUSIONS

The results indicate that though perfectionism seems to be related to both pre-existing and future insomnia, its role seems relatively weak.

Perfectionism and the cortisol response to psychosocial stress in men

OBJECTIVE

To test the hypothesis that perfectionism is an important moderator of the neuroendocrine stress response, with higher perfectionism predicting increased neuroendocrine activation.

METHODS

A total of 50 middle-aged men underwent an acute standardized psychosocial stress task (Trier Social Stress Test). Perfectionism, cognitive appraisal of the stressful situation, trait anxiety, and various personality characteristics were assessed with questionnaires. Salivary cortisol, plasma epinephrine and norepinephrine, blood pressure, and heart rate were analyzed before and after stress. Circadian profiles of cortisol secretion during the day and in response to awakening were analyzed to assess basal activity of the hypothalamus-pituitary-adrenal (HPA) axis. Multiple regression analyses were conducted to identify predictors of the neuroendocrine stress response.

RESULTS

Perfectionism was significantly associated with area under the total response curve with respect to increase (AUCi) of cortisol (r = 0.322, p = .046), but not with AUCi of norepinephrine (r = -0.217, p = .152) or AUCi of epinephrine (r = 0.116, p = .477). Hence, AUCi of cortisol was the main criterion. As possible predictors, trait anxiety, neuroticism, vital exhaustion, secondary appraisal, depression, and openness were considered. Regression analyses demonstrated that only perfectionism (beta = 0.45, p = .002) and secondary appraisal (beta = 0.50, p = .001) were independent predictors of AUCi of cortisol, the final model explaining 45% of the total variance in cortisol response (R2 = 0.45, "shrunken" R2 [sR2] = 0.38); perfectionism alone accounted for 18% of this variance (deltaR2 = 0.18, sR2 = 0.19).

CONCLUSION

The typical cognitions, and presumably the associated emotions, of perfectionists seem to contribute independently to stress-induced bodily responses, including HPA axis activation, in response to psychosocial stress.

The role of dichotomous thinking and rigidity in perfectionism

Perfectionism is a complex psychological construct that has been defined in many different ways. Recent conceptualisations of perfectionism have involved dividing the construct into positive and negative components. Negative perfectionism is associated with high emotional distress whereas positive perfectionism is associated with positive affect and lower levels of distress. Although these distinctions have been made it remains unclear as to how distinct the two aspects of perfectionism are particularly in terms of their cognitive profiles. This study investigated two cognitive constructs that have been theoretically linked to perfectionism. Dichotomous thinking and rigidity were examined in three samples (40 clinical participants, 111 athletes, 101 students). As hypothesised, the clinical sample had the highest score on negative perfectionism, however, no differences were observed between groups on positive perfectionism. Dichotomous thinking emerged as the variable most predictive of negative perfectionism, and was less strongly related to positive perfectionism. These results highlight the importance of dichotomous thinking as a cognitive construct worthy of further research to understand negative perfectionism. Implications for the development of cognitive therapy interventions for negative perfectionism are discussed.

Fast Psychomotor Functioning in Anorexia Nervosa: Effect of Weight Restoration

In a previous study young seriously underweight anorexia nervosa (AN) patients in the early phase of treatment were found to react faster in psychomotor tasks. To further understand this finding we studied the impact of weight restoration on the performance of AN patients in drawing and copying tasks. A group of 17 female AN patients, aged 14 to 25, was compared with 17 healthy controls, matched for sex, age and educational level. Patients were tested when severely underweight and after weight restoration. Control subjects were also tested twice. Using computerized recording and analysis of writing and drawing behavior, reaction times and drawing times were derived, while cognitive and motor demands were manipulated. Overall, AN patients showed shorter reaction times in copying tasks and shorter drawing time in the drawing task than normal controls, and this pattern persisted after weight restoration. No significant group (AN vs. controls) by session (test vs. retest) effect emerged. The finding of a consistent pattern of shorter reaction and drawing times in AN patients before and after weight restoration is compatible with a personality characteristic of perfectionism and overachievement in AN patients.

Positive conceptions of perfectionism: approaches, evidence, challenges

Almost 30 years ago, Hamachek (1978) suggested that 2 forms of perfectionism be distinguished, a positive form labeled "normal perfectionism" and a negative form labeled "neurotic perfectionism." Focusing on the positive, we present an overview of the different empirical conceptions of the 2 forms of perfectionism and a common framework for the 2 basic approaches: the dimensional approach differentiating 2 dimensions of perfectionism (perfectionistic strivings and perfectionistic concerns) and the group-based approach differentiating 2 groups of perfectionists (healthy perfectionists and unhealthy perfectionists). Moreover, we review the evidence demonstrating that (a) perfectionistic strivings are associated with positive characteristics and (b) healthy perfectionists show higher levels of positive characteristics compared to unhealthy perfectionists and nonperfectionists. Although questions on core facets, positive effects, and developmental antecedents of positive forms of perfectionism remain, our findings suggest that self-oriented perfectionistic strivings are positive, if perfectionists are not overly concerned about mistakes and negative evaluations by others.

Action monitoring and perfectionism in anorexia nervosa

To study action monitoring in anorexia nervosa, behavioral and EEG measures were obtained in underweight anorexia nervosa patients (n=17) and matched healthy controls (n=19) while performing a speeded choice-reaction task. Our main measures of interest were questionnaire outcomes, reaction times, error rates, and the error-related negativity ERP component. Questionnaire and behavioral results indicated increased perfectionism in patients with anorexia nervosa. In line with their perfectionism and controlled response style patients made significantly less errors than controls. However, when controlling for this difference in error rates, the EEG results demonstrated a reduced error-related negativity in the patient group. These seemingly contradictory outcomes of improved performance and reduced error monitoring are discussed in relation with indications of anterior cingulate cortex hypoactivity in anorexia nervosa patients.

Perfectionism and eating attitudes in Portuguese university students

OBJECTIVES

The main objective was to explore which are the dimensions of perfectionism that are linked to disordered eating behaviour (EB) in a large non-clinical sample of both genders.

METHOD

One thousand one hundred and sixty-three undergraduate students of the University of Coimbra completed the Portuguese versions of the multidimensional perfectionism scale (MPS) and the eating attitudes test (EAT-40).

RESULTS

In both genders, the MPS total score was associated with the EAT total score and all EAT dimensions (except for socially prescribed perfectionism in females). Self-oriented perfectionism (SOP) and socially prescribed perfectionism (SPP) were associated with EAT total score, diet concerns (DC) and bulimic behaviour (BB) in females while in males the social prescribed perfectionism (SPP) was the useful predictor of EAT total score, BB and social pressure to eat (SPE).

CONCLUSION

These results confirm that in general high levels of perfectionism are associated with abnormal EB. This was the case for both genders for SPP but for SOP for females only. The association for other oriented perfectionism (OOP) was greater for males than for females.

The interaction of perfectionism, perceived weight status, and self-esteem to predict bulimic symptoms: the role of 'benign' perfectionism

The present study sought to replicate an interactive model of global perfectionism, perceived weight status, and self-esteem in predicting bulimic symptom development in a sample of young women [Bardone-Cone, et al. (2006). Predicting bulimic symptoms: An interactive model of self-efficacy, perfectionism, and perceived weight status. Behaviour Research and Therapy, 44, 27-42; Vohs, K. D., et al. (1999). Perfectionism, perceived weight status, and self-esteem interact to predict bulimic symptoms: A model of bulimic symptom development. Journal of Abnormal Psychology, 108, 695-700; Vohs, K. D., et al. (2001). Perfectionism, body dissatisfaction, and self-esteem: An interactive model of bulimic symptom development. Journal of Social and Clinical Psychology, 20, 476-497]. The aim was to investigate the role of 'problematic' and 'benign' perfectionism within this model, using data from 95 female university students over a 3-month period. Contrary to hypotheses, multivariate analyses revealed a significant three-way interaction only between 'benign' perfectionism, perceived weight status and self-esteem in predicting change in bulimic symptoms over a 3-month period. The predictive effect of the interaction between 'benign' perfectionism and perceived weight status on bulimic symptoms was strongest for women with high self-esteem, for whom feeling overweight and having perfectionistic attitudes preceded increased bulimic symptoms. These findings suggest that high self-esteem is insufficient to protect against the development of bulimic symptoms when both the perception of oneself as being overweight, and high levels of perfectionistic standards, are present. It would appear that the role of perfectionism within the context of disordered eating is complex.

What are the roles of perfectionism and responsibility in checking and cleaning compulsions?

Empirical findings revealed that an inflated sense of responsibility has a major impact on obsessive-compulsive symptomatology (OCS). Another cognitive variable, perfectionism, is also theoretically linked to OCS. The assumption about the insufficient but necessary role of perfectionism for OCS and the view of perfectionism as a manifestation of avoidance of serious consequences led us to explore the role of an important cognitive mediator (responsibility) in this relationship. The present study aimed to explore the mediational role of responsibility for the effects of perfectionism on checking and cleaning symptom profiles of OCS in a nonclinical population in Turkey. Findings of the present study suggested that responsibility appraisals mediate effects of self-oriented and socially prescribed perfectionism on checking and the effect of socially prescribed perfectionism on cleaning. There was a partial mediation for self-oriented perfectionism on cleaning. The findings are discussed within the scope of current literature and implications for clinical applications are suggested.

Self-Worth Appraisal of Life Events and Beck’s Congruency Model of Depression Vulnerability

Congruency theory predicts that sociotropic and autonomous individuals may experience negative life events differently, focusing primarily on the social and achievement themes of events, respectively. The present study investigated this hypothesis in 175 undergraduate students, who completed measures of sociotropy and autonomy, depressive symptoms, and life event self-worth impact appraisals. Both negative interpersonal and personal failure-related events were related to participants’ senses of self-worth in the social and achievement domains, supporting a continuous model of life event classification. Sociotropy and specific autonomy subfactors showed differential associations with self-worth impact ratings. Recommendations for future research, psychological assessment, and treatment of depressive responses to negative life events in sociotropic and autonomous individuals are discussed.

Personal standards and evaluative concerns dimensions of “clinical” perfectionism: A reply to Shafran et al. (2002, 2003) and Hewitt et al. (2003)

Shafran, Cooper, and Fairburn (2002, 2003) provided a cognitive-behavioral analysis of "clinical" perfectionism, a construct they considered to involve both the determined pursuit of self-imposed standards and extremely vulnerable self-evaluation. They argued against a multidimensional perspective to studying perfectionism. We respond to Shafran et al. (2002, 2003) and Hewitt, Flett, Besser, Sherry, and McGee's (2003) reply to Shafran et al. (2002) by considering the theoretical, empirical, and clinical implications of findings identifying two higher-order dimensions of perfectionism reflecting personal standards (PS) and self-critical evaluative concerns. Analyses of data from two diverse study groups, a college student sample (N = 527) and a clinical sample of patients with binge eating disorder (N = 236), revealed that self-criticism accounts for the relation between perfectionism measures and depressive, anxious, and eating disorder symptoms. We conclude that possessing high PS is not by itself maladaptive. Rather, self-critical evaluative tendencies are more relevant than PS to the critical processes Shafran et al. (2002) suggested contribute to the maintenance of clinical perfectionism.

Control theory and psychopathology: an integrative approach

Perceptual control theory (PCT; Powers, 1973) is presented and adapted as a framework to understand the causes, maintenance, and treatment of psychological disorders. PCT provides dynamic, working models based on the principle that goal-directed activity arises from a hierarchy of negative feedback loops that control perception through control of the environment. The theory proposes that psychological distress arises from the unresolved conflict between goals. The present paper integrates PCT, control theory, and self-regulatory approaches to psychopathology and psychotherapy and recent empirical findings, particularly in the field of cognitive therapy. The approach aims to offer fresh insights into the role of goal conflict, automatic processes, imagery, perceptual distortion, and loss of control in psychological disorders. Implications for psychological therapy are discussed, including an integration of the existing work on the assessment of control profiles and the use of assertive versus yielding modes of control.

Difficulties in the assessment of personality traits and disorders in eating-disordered individuals

There are compelling reasons to examine personality variables in the eating disorder (ED) field but many impediments to the collection of useful data. In addition to the conceptual and methodological difficulties associated with personality assessment in the general case, the EDs present a number of special problems. These include patients' young age at onset and evaluation, the "state" effects of semi-starvation and chaotic eating, denial and distortion in self-report, the instability of ED subtypes, and the intrusion of eating and weight concerns into a wide range of apparently unrelated domains. Although there is substantial support for the clinical view that personality variables are linked to anorexia nervosa (AN) and bulimia nervosa (BN), the identification of stable traits and Axis II disorders in individual patients should be deferred until after the initial phase of treatment.

Cognitive appraisals in young people with obsessive-compulsive disorder

BACKGROUND

A number of cognitive appraisals have been identified as important in the manifestation of obsessive-compulsive disorder (OCD) in adults. There have, however, been few attempts to explore these cognitive appraisals in clinical groups of young people.

METHOD

This study compared young people aged between 11 and 18 years with OCD (N = 28), young people with other types of anxiety disorders (N = 28) and a non-clinical group (N = 62) on three questionnaire measures of cognitive appraisals. These were inflated responsibility (Responsibility Attitude Scale; Salkovskis et al., 2000), thought-action fusion--likelihood other (Thought-Action Fusion Scale; Shafran, Thordarson & Rachman, 1996) and perfectionism (Multidimensional Perfectionism Scale; Frost, Marten, Luhart & Rosenblate, 1990).

RESULTS

The young people with OCD had significantly higher scores on inflated responsibility, thought-action fusion--(likelihood other), and one aspect of perfectionism, concern over mistakes, than the other groups. In addition, inflated responsibility independently predicted OCD symptom severity.

CONCLUSIONS

The results generally support a downward extension of the cognitive appraisals held by adults with OCD to young people with the disorder. Some of the results, however, raise issues about potential developmental shifts in cognitive appraisals. The findings are discussed in relation to implications for the cognitive model of OCD and cognitive behavioural therapy for young people with OCD.

An experimental analysis of the role of schema compensation in anorexia nervosa

It has been suggested that the relatively poor effectiveness of treatments for anorexia nervosa is due to a poor conceptualisation of the disorder. One hypothesis is that current models are mistakenly targeting superficial, instead of deeper level, cognitions and cognitive processes. A schema-based cognitive-behavioural model of eating disorder pathology suggests that the process of schema compensation is key to restrictive pathology-when there is the threat of experiencing negative affect, compensatory schemas are activated, reducing that affect. The current experimental study aimed to provide support for such a process. Eating-disordered and control women completed a computer-based task, measuring the compensation process in terms of speed and accuracy in response to subliminal threat cues. The results did not fully support the hypothesis, suggesting that the model and methodology need some amendment. Improvements to the methodology are discussed.

Athletics, perfectionism, and disordered eating

OBJECTIVES

To determine the effects of sex, perfectionism, level of athletic participation (varsity vs. recreational), and type of sport (swimming, running, or soccer) on disordered eating.

METHOD

Male and female swimmers, runners, and soccer players at Stanford University were recruited at both the recreational and varsity level. Athletes were given the Multidimensional Perfectionism Scale (MPS), the Eating Attitudes Test-26 (EAT-26), the Eating Disorders Examination Questionnaire (EDE-Q), and a survey on demographics and level of athletic competition. Of 257 athletes identified, 250 (97.3%) returned the questionnaires.

RESULTS

A Multivariate Analysis of Variance (MANOVA) was used to assess the variables' effects on disordered eating attitudes. Significant main effects were found for Sex (F5,199=25.7, p<0.001), Level (F5,199=2.5, p<0.05), and Perfectionism (F10,400=3.0, p<0.001). Only two of the ten interaction terms were significant: Sex by Level of athletic participation (F5,199=3.2, p<0.01) and Sex by Perfectionism (F10,400=2.1, p<0.05). Females displayed higher disordered eating than males. Disordered eating attitudes increased with perfectionism and were greater for recreational athletes than varsity, but this trend was significant for females only. Type of sport showed no significant effects. When examining physiological data a higher percentage of varsity females had irregular periods (42.9%) or amenorrhea (14.3%) than recreational females (13.4% and 2.9%, respectively).

DISCUSSION

Males showed little variability in their data due to low disordered eating scores overall, thus demonstrated few significant results. The greatest risk factor for disordered eating attitudes for females was perfectionism, which crossed all athletic divisions. Although recreational athletes seemed more at risk psychologically, the varsity athletes had more physiological risk.

A new measure of perfectionism: the Perfectionism Inventory

In this investigation, we produced a new 8-scale measure of perfectionism called the Perfectionism Inventory (PI) that is designed to capture the important constructs provided by 2 existing Multidimensional Perfectionism Scale (MPS; Frost, Marten, Lahart, & Rosenblate, 1990; Hewitt & Flett, 1991b) measures, along with new perfectionism scales. In the results from 3 studies, we describe scale development, scale psychometric properties, and criterion-related validity evidence for the 8 PI scales: Concern Over Mistakes, High Standards for Others, Need for Approval, Organization, Parental Pressure, Planfulness, Rumination, and Striving for Excellence. We present relationships between the 8 PI scales, relevant MPS scales, and other criterion measures. Second-order exploratory and confirmatory analyses provide support for the 8-scale PI model as well as support for 2 composite PI factors labeled Conscientious Perfectionism and Self-Evaluative Perfectionism.

Fast psychomotor functioning in underweight anorexia nervosa patients

To explore whether underweight anorexia nervosa patients show psychomotor differences relative to normal controls, 32 female hospitalised patients, aged between 14 and 25 years, were compared with 32 healthy, normal weight controls, matched for sex, age and educational level. Using computerised analysis of writing and drawing behaviour, reaction times and movement times and their different components were analysed, while cognitive and motor demands were manipulated in five drawing and copying tasks. Anorexia nervosa patients were, compared to normal weight controls, significantly faster in a drawing task and showed shorter reaction times in copying tasks. Movement times did not differ significantly between the two groups. In the most complex copying task, a significant group x complexity interaction for reaction time (patients shorter) and reinspection time (patients longer) was found. Patients also made more errors than controls. The finding of a consistent pattern of shorter reaction times in underweight anorexia nervosa patients seems to run contrary to previous findings of disturbed cognitive functioning (i.e. impaired attention) in these patients. The differences seem to be related to cognitive factors more than to motor (executive) components.

Sociotropy and autonomy: an examination of interpersonal and work adjustment

One-hundred and sixty-five undergraduate students completed measures of sociotropy, autonomy, and adjustment. Autonomy was associated with poor social adjustment but was not associated with work role adjustment. Sociotropy failed to evidence a significant relation with work role or social adjustment. In past research, autonomy has primarily been theorized to contribute to depression when achievement needs are not met. Our results raise the possibility that autonomy may be linked to depression through the pathway of low social support and interpersonal difficulties. In addition, the results suggest that sociotropic individuals may not have objectively poor social adjustment despite their concerns regarding this area. Likewise, autonomous individuals may not have better or worse work adjustment despite their efforts to achieve.

The correlation between thought-action fusion and religiosity in a normal sample

Thought-action fusion (TAF) refers to a set of two cognitive biases that are thought to contribute to the inflation of feelings of responsibility for one's own thoughts, and thus to the development of obsession. Therefore, insight into the origins of TAF is a clinically relevant research topic. The present study examined the association between religiosity and TAF. Undergraduate students (N=100) completed questionnaires concerning religion, TAF and obsessive-compulsive complaints. Results indicate that religiosity is, indeed, correlated with certain aspects of TAF. Furthermore, correlational patterns differed between Catholic and Protestant subsamples.

The Tripartite Influence model of body image and eating disturbance: a covariance structure modeling investigation testing the mediational role of appearance comparison

Recent theoretical approaches to the etiology of eating disorders and body image disturbances have begun to focus on multifactorial models. In the current study, the Tripartite Influence model was examined in a large sample of college females (ages 18-22). This model proposes that three primary core sources of influence--parents, peers and media--contribute to the development of body image and eating disturbances. Additionally, the model suggests that at least two factors mediate the relationship between influences and disturbance-appearance comparison and internalization of media information. In this study, appearance comparison was examined as a mediational link between peer, family and media influence variables and the outcome disturbance measures of eating dysfunction and body image dissatisfaction. Covariance structure modeling (CSM) was used to test the proposed pathways. The results indicated that appearance comparison mediated the effects of family and media influences on body dissatisfaction, which in turn influenced restrictive and bulimic behaviors. In addition, peer influences had a direct influence on restriction. Perfectionism was hypothesized to relate to body dissatisfaction, but was in fact found to influence appearance comparison. The findings were limited by the necessity of several modifications to the originally proposed models, yet offer replication and extension of previous work with appearance comparison and support for further testing of the Tripartite Influence model.

Clinical perfectionism: a cognitive-behavioural analysis

This paper reviews the characteristics of clinical perfectionism and proposes a new definition of the phenomenon. It is suggested that the defining feature of clinically significant perfectionism is the overdependence of self-evaluation on the determined pursuit (and achievement) of self-imposed personally demanding standards of performance in at least one salient domain, despite the occurrence of adverse consequences. It is suggested that such clinical perfectionism is maintained by the biased evaluation of the pursuit and achievement of personally demanding standards. Specifically, it is suggested that people with perfectionism react to failure to meet their standards with self-criticism. If they do meet their standards, the standards are re-evaluated as being insufficiently demanding. Anorexia nervosa and bulimia nervosa are considered to have a particular relationship to perfectionism, with both disorders often being direct expressions of perfectionism. Under these circumstances self-evaluation is dependent on the pursuit and attainment of personally demanding standards in the domain of control over eating, shape and weight. The implications of this analysis for research and practice are considered.

Personality and Psychopathology in Nonepileptic Attack Disorder and Epilepsy: A Prospective Study

To study the nature of personality and psychopathology in nonepileptic attack disorder (NEAD) and epilepsy, we prospectively assessed 45 consecutive attendees to a specialist assessment unit for epilepsy. Patients with NEAD were more likely to report clinically significant symptoms of anxiety, worry, disordered eating, and somatoform disorder. An ICD-10 diagnosis of anxiety or phobic disorder was significantly more common in NEAD patients. Together DSM-IV personality Clusters A and C were more common in epilepsy than NEAD. Hierarchical logistic regression with diagnosis as the target variable found anxiety, eating, and worry but not somatoform symptoms were reliably associated with NEAD. Together the Present State Examination (PSE) eating, PSE worrying/tension, PSE expansive mood, past psychiatric history, and gender variables allowed for correct classification of more than 88% of all cases. Personality and psychopathology variables seem to be valid clinical predictors of epilepsy and NEAD, and should be examined in epidemiological studies.