Perfectionism as a transdiagnostic process: A clinical review

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Author's personal copy Clinical Psychology Review 31 (2011) 203–212

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Clinical Psychology Review

Perfectionism as a transdiagnostic process: A clinical review Sarah J. Egan a,⁎, Tracey D. Wade b, Roz Shafran c a b c

School of Psychology and Speech Pathology & Curtin Health Innovation Research Institute, Curtin University, Australia School of Psychology, Flinders University, Australia School of Psychology, University of Reading, United Kingdom

a r t i c l e

i n f o

Available online 5 May 2010 Keywords: Perfectionism Transdiagnostic Eating disorders Anxiety Depression

a b s t r a c t Perfectionism is a risk and maintaining factor for eating disorders, anxiety disorders and depression. The objective of this paper is to review the four bodies of evidence supporting the notion that perfectionism is a transdiagnostic process. First, a review of the literature was conducted that demonstrates the elevation of perfectionism across numerous anxiety disorders, depression, and eating disorders compared to healthy controls. Data is presented that shows perfectionism increases vulnerability for eating disorders, and that it maintains obsessive–compulsive disorder, social anxiety and depression as it predicts treatment outcome in these disorders. Second, evidence is examined showing that elevated perfectionism is associated with co-occurrence of psychopathology. Third, the different conceptualisations of perfectionism are reviewed, including a cognitive-behavioural conceptualisation of clinical perfectionism that can be utilised to understand this transdiagnostic process. Fourth, evidence that treatment of perfectionism results in reductions in anxiety, depression and eating pathology is reviewed. Finally, the importance of clinicians considering the routine assessment and treatment of perfectionism is outlined. Crown Copyright © 2010 Published by Elsevier Ltd. All rights reserved.

Contents 1. 2. 3.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Measurement of perfectionism . . . . . . . . . . . . . . . . . . . . . . . . . . Evidence for the transdiagnostic nature of perfectionism . . . . . . . . . . . . . . 3.1. The presence of elevated perfectionism across disorders . . . . . . . . . . . 3.1.1. Eating disorders . . . . . . . . . . . . . . . . . . . . . . . . . 3.1.2. Depression, bipolar disorder and suicidal ideation. . . . . . . . . . 3.1.3. Anxiety disorders . . . . . . . . . . . . . . . . . . . . . . . . . 3.1.4. Personality disorders . . . . . . . . . . . . . . . . . . . . . . . 3.2. Perfectionism as an explanation for co-occurrence of disorders . . . . . . . . 3.3. Perfectionism and cognitive-behavioural theories of maintenance of disorders 3.4. Treatment of perfectionism . . . . . . . . . . . . . . . . . . . . . . . . 3.4.1. Perfectionism has a negative impact on treatment outcome . . . . . 3.4.2. Outcome data for treatment of perfectionism . . . . . . . . . . . . 4. Clinical implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1. Assessment and individualised case conceptualisation . . . . . . . . . . . . 4.2. Directly target perfectionism early in treatment . . . . . . . . . . . . . . . 5. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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1. Introduction

⁎ Corresponding author. School of Psychology and Speech Pathology, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia. Tel.: +61 89266 2367; fax: +61 89266 3178. E-mail address: [email protected] (S.J. Egan).

Perfectionism has been implicated in the aetiology and maintenance of eating disorders, anxiety disorders and depression (Shafran & Mansell, 2001). In an earlier review, Shafran and Mansell demonstrated a clear association between perfectionism and psychopathology, and

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evidence has further accumulated since their review demonstrating that perfectionism is elevated in many disorders compared to healthy controls. The aim of this paper is to review evidence supporting the notion that perfectionism is a transdiagnostic process. For the purposes of this paper, we consider a transdiagnostic process not simply as one which occurs across different diagnoses but also one that is either a risk factor for the disorder or a maintaining mechanism. The simple occurrence of processes across different disorders is of limited interest, but the demonstration that such processes contribute to the aetiology and maintenance of psychopathology has important implications for transdiagnostic prevention and treatment. For this reason the focus on the paper is on prospective studies and studies that inform the question of shared maintaining mechanisms across disorders, rather than simple association studies. Finally, it is arguable whether perfectionism is a personality characteristic, a set of cognitivebehavioural features, a symptom of psychopathology or a ‘process.’ We consider that it falls within the definition of a process as “an aspect of cognition or behaviour that may contribute to the maintenance of a psychological disorder” (Harvey, Watkins, Mansell, & Shafran, 2004, p. 14), and therefore it is legitimately included in this special issue examining common factors in the aetiology and maintenance of multiple psychiatric disorders. 2. Measurement of perfectionism Perfectionism has been proposed to be a multidimensional construct which has been predominately measured by two Multidimensional Perfectionism Scales (MPS); the 35-item FMPS (Frost, Marten, Lahart, & Rosenblate, 1990) and the 45-item HMPS (Hewitt & Flett, 1991a). The FMPS was developed through deriving theoretically based items plus items that were taken from existing measures of perfectionism (e.g., Burns Perfectionism Scale (BPS); Burns, 1980), eating disorder psychopathology (Eating Disorders Inventory Perfectionism subscale (EDI-P); Garner, Olmsted, & Polivy, 1983) and obsessive–compulsive disorder (OCD) symptomatology (Maudsley Obsessional Compulsive Inventory (MOCI); Hodgson & Rachman, 1977). Frost et al. (1990) found a 6-factor solution consisting of: Personal Standards (PS; setting high standards), Concern over Mistakes (CM; negative reactions to mistakes and perceiving mistakes as failures), Doubts about Actions (DA; doubting one's own performance), Parental Expectations (PE; parents setting high standards), Parental Criticism (PC; parents criticising for mistakes), and Organisation (O; organisation and neatness). This latter subscale is not included in the total score. Enns and Cox (2002) have concluded there is “…compelling evidence of the construct, concurrent, and discriminant validity of the Frost MPS” (p. 42). The other commonly utilised measure of perfectionism is the HMPS (Hewitt & Flett, 1991a). In addition to perceiving perfectionism as a selffocused construct, Hewitt and Flett conceptualise it as also having interpersonal components. The 45 item scale is divided into three subscales. The self-oriented perfectionism subscale relates to setting high standards for achievement and self-criticism for not meeting standards, similar to the PS and CM subscales of the FMPS (Frost et al., 1990). The other-oriented perfectionism subscale includes items that relate to having high standards for other people that are unrealistic. The sociallyprescribed perfectionism subscale items are related to perceiving that other people hold unrealistically high standards for the individual. Good internal consistency, convergent and discriminant validity has been demonstrated, and it has predictive validity in a wide range of psychiatric diagnoses (Enns & Cox, 2002). Factor analyses using both scales have shown a two factor solution, consisting of maladaptive evaluative concerns (CM, DA, PC, PE and self-oriented perfectionism) and positive (achievement) striving (PS, O and other-oriented perfectionism) (Bieling, Israeli, & Antony, 2004; Frost, Heimberg, Holt, Mattia, & Neubauer, 1993). Clearly there is overlap between the scales even though they reflect different views

on the core nature of perfectionism. It is these scales that have typically been used to investigate perfectionism across a number of psychopathologies, contributing to four different areas of enquiry that indicates the transdiagnostic nature of perfectionism. First, perfectionism has been implicated as a risk and maintenance factor across different psychopathologies. Second, elevated perfectionism is associated with co-occurrence of psychopathology. Third, perfectionism is included as an explanatory mechanism in the maintenance of a variety of psychopathologies. Fourth, treating perfectionism reduces a variety of psychopathologies. Each of these bodies of evidence is now examined in turn. 3. Evidence for the transdiagnostic nature of perfectionism 3.1. The presence of elevated perfectionism across disorders 3.1.1. Eating disorders Evidence from a number of areas supports the suggestion that perfectionism increases, and maintains, eating disorder pathology. First, as seen in Table 1, numerous studies have shown that individuals with anorexia nervosa (AN) and bulimia nervosa (BN) have significantly higher perfectionism than controls (Bastiani, Rao, Weltzin, & Kaye, 1995; Cockell et al., 2002; Halmi et al., 2000; Niv, Kaplan, Mitrani, & Shiang, 1998; Lilenfeld et al., 2000; Moor, Vartanian, Touyz, & Beumont, 2004; Sassaroli et al., 2008). Second, retrospective childhood reports of perfectionism are associated with later development of an eating disorder (Southgate, Tchanturia, Collier, & Treasure, 2008), including AN (Fairburn, Cooper, Doll, & Welch, 1999) and BN (Fairburn, Welch, Doll, Davies, & O'Connor, 1997). Third, perfectionism has been shown to prospectively predict growth of bulimic symptoms in female students (Steele, Corsini, & Wade, 2007; Vohs, Bardone, Joiner, & Abramson, 1999). Fourth, individuals who have recovered from AN continue to show elevated perfectionism compared to controls (Bardone-Cone et al., 2007) for up to 16 years post admission (Nilsson, Sundbom, & Hagglof, 2008). Fifth, twin studies suggest that some genetic and environmental risk factors for disordered eating are shared with perfectionism. Wade and Bulik (2007) showed that around 6% of the variance of genetic risk factors, and 3% of environmental risk factors, were shared between perfectionism and one of the diagnostic criterion for AN and BN, selfevaluation being based on weight and shape. Using the same twin data, Wade et al. (2008) determined that female co-twins of AN probands had significantly higher PS than controls, and concluded that AN may be an expression of a genetic temperament style that includes striving for perfection. It is an important question for future epigenetic research to determine if reducing perfectionism can reduce the likelihood of transmission of an eating disorder to the next generation. A number of systematic reviews have concluded that, based on the extant evidence, perfectionism is likely to be a risk factor for eating disorders (e.g., Bardone-Cone et al., 2007; Jacobi, Hayward, de Zwaan, Kraemer, & Agras, 2004; Lilenfield, Wonderlich, Riso, Crosby, & Mitchell, 2006; Stice, 2002). It is important to note both CM and PS are considered to be risk factors for eating disorders, in contrast to individuals with anxiety and depression where PS has most often not been associated with distress (see Stoeber & Otto, 2006 for a review). In support of this, Sassaroli et al. (2008) found a mixed eating disorder group (AN, BN) had significantly higher PS than individuals with depression and OCD. Confirming this view is evidence by Steele et al. (2007) which demonstrated that PS preceded bulimic symptoms in undergraduate university females over a 3 month period. In addition, PS and not CM was found to share risk with AN in the aforementioned twin study (Wade et al., 2008). Thus, achievement striving and high personal standards appear to not be associated with positive functioning in eating disordered samples. 3.1.2. Depression, bipolar disorder and suicidal ideation Perfectionism has been construed as a ‘destructive’ force in depression (Blatt, 1995). As seen in Table 1, perfectionism is elevated

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Table 1 Summary of means (and standard deviations) of perfectionism subscales in clinical groups compared to non-clinical controls. Study Eating disorder samples Bastiani et al. (1995) Underweight AN Weight restored AN Non-clinical controls Srinivasagam et al. (1995) Recovered AN Non-clinical controls Niv et al. (1998) AN Non-clinical controls Halmi et al. (2000) Restricting AN Purging AN Binge eating and purging AN Non-clinical controls Lilenfeld et al. (2000) BN BN recovered Non-clinical controls Cockell et al. (2002) AN Non-clinical controls Moor et al. (2004) AN BN EDNOS Non-clinical controls Sassaroli et al. (2008) AN and BN Depression OCD Non-clinical controls Depression samples Hewitt and Flett (1991b) Depression Mixed anxiety disorders Non-clinical controls Enns et al. (2001) Depression Non-clinical controls Mixed samples Hewitt et al. (1994) Borderline personality disorder Schizophrenia Non-clinical controls Anxiety disorder samples Frost et al. (1994) Subclinical OCD Non-clinical controls Juster et al. (1996) Social phobia Non-clinical controls Frost and Steketee (1997) OCD Panic disorder Non-clinical controls Antony et al. (1998) Social phobia OCD Panic disorder Specific phobia Non-clinical controls Saboonchi et al. (1999) Social phobia Panic disorder Non-clinical controls Iketani et al (2002) Panic disorder Non-clinical controls Buhlmann et al. (2008) OCD BDD Non-clinical controls

n

CM

PS

SOP

SPP

EDI-P

11 8 10

34.0 (13.0)* 27.0 (11.0)* 15.0 (4.0)

28.0 (7.0)* 27.0 (8.0) 20.0 (5.0)

84.0 (24.0)* 77.0 (23.0)* 53.0 (9.0)

60.0 (22.0)* 47.0 (15.0) 36.0 (10.0)

8.0 (5.0)* 9.0 (5.0)* 2.0 (2.0)

20 16

29.0 (10.0)* 15.0 (4.0)

27.0 (4.0) 22.0 (4.0)

– –

– –

9.0 (5.0)* 2.0 (3.0)

29 67

– –

– –

– –

– –

8.96* 5.28

(9.6)* (8.9)* (8.2)* (5.20)

27.6 (6.5)* 26.8 (6.4)* 13.6 (3.6)* 15.05 (4.2)

– – – –

– – – –

– – – –

31 14 44

24.5 (6.1)* 25.0 (4.7)* 15.0 (4.3)

23.5 (6.1)* 22.3 (5.8)* 19.7 (5.2)

– – –

– – –

6.7 (3.9)* 5.9 (3.7)* 2.8 (2.7)

21 21

– –

– –

89.0 (6.2)* 65.8 (7.5)

69.7 (5.7)* 54.4 (6.9)

– –

27 23 19 25

– – – –

– – – –

– – – –

– – – –

8.5 (4.5)* 9.1 (5.1)* 6.9 (4.8)* 4.8 (3.6)

39 25 37 44

35.1 27.8 29.0 19.4

26.61 (5.7)* 24.0 (5.5) 23.8 (5.8) 21.9 (4.8)

– – – –

– – – –

– – – –

22 13 22

– – –

– – –

75.1 (12.5)* 64.4 (15.6) 63.5 (15.7)

60.1 (20.1)* 58.4 (13.1)* 42.6 (12.7)

– – –

27.0 (8.3)* 18.8 (5.9)

22.1 (5.5) 23.1 (5.2)

65.8 (18.8)* 68.7 (13.1)

58.6 (16.6)* 47.9 (12.4)

– –

13 13 13

– – –

– – –

67.9 (19.1) 68.3 (20.1) 67.5 (18.6)

66.2 (13.2)* 52.7 (11.4) 56.4 (12.3)

– – –

41 44

27.2 (7.1)* 19.6 (7.3)

27.2 (4.6)* 23.1 (3.2)

– –

– –

– –

61 39

25.6 (7.5)* 20.3 (6.7)

23.1 (5.8) 23.4 (4.9)

– –

– –

– –

35 14 35

24.3 (9.8)* 26.2 (10.0)* 18.5 (7.2)

22.9 (6.8) 24.8 (5.7) 22.4 (5.5)

– – –

– – –

– – –

70 45 44 15 49

27.5 21.5 24.1 18.2 17.4

22.4 21.9 22.7 21.9 22.7

70.5 (17.6) 69.5 (18.9) 71.6 (13.7) 63.1 (21.9) 64.1 (15.2)

57.8 (15.5)* 51.3 (15.2)* 55.7 (13.0)* 43.5 (13.1) 44.1 (11.2)

– – – – –

145 116 59 44

161 141

31.8 32.8 34.0 19.7

(8.3)* (5.9)* (7.7)* (4.8)

(8.4)* (7.9)* (8.2)* (5.7) (5.3)

(5.9) (6.4) (4.3) (6.3) (6.1)

52 55 113

26.7 (7.6)* 22.7 (7.8) 19.7 (6.4)

21.8 (6.0) 19.6 (6.2) 20.5 (5.0)

– – –

– – –

– – –

59 35

24.1 (6.9)* 19.5 (6.8)

19.0 (6.0)* 15.6 (4.6)

– –

– –

– –

21 19 21

24.9 (9.4)* 25.2 (9.7)* 15.0 (4.5)

25.4 (8.4) 22.6 (6.4) 24.1 (5.4)

– – –

– – –

– – –

Note. CM = Concern over Mistakes, PS = Personal Standards subscales of the Frost Multidimensional Perfectionism Scale (Frost et al., 1990); SOP = self-oriented perfectionism, SPP = socially-prescribed perfectionism, of the Hewitt and Flett Multidimensional Perfectionism Scale (Hewitt & Flett, 1991a,b); EDI-P = Eating Disorders Inventory-Perfectionism subscale (Garner et al., 1983); AN = Anorexia Nervosa; BN = Bulimia Nervosa; EDNOS = Eating Disorder not otherwise specified; OCD = Obsessive–Compulsive Disorder; BDD = Body Dysmorphic Disorder, *indicates the clinical group was significantly higher on the perfectionism measure compared to the control group within the study at p b .05.

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in individuals with depression compared to healthy controls (Enns, Cox, & Borger, 2001; Hewitt & Flett, 1991b; Sassaroli et al., 2008). Furthermore, in clinically depressed samples, depressive symptoms correlate with self-oriented perfectionism (Norman, Davies, Nicholson, Cortese, & Malla, 1998) and CM (Huprich, Porcelli, Keaschuk, Binienda, & Engle, 2008). Thus, in samples of individuals with both eating disorders and depression, self-oriented perfectionism has been found to be correlated with psychopathology. In terms of prospective studies, in a non-clinical sample, sociallyprescribed perfectionism has been found to predict an increase in depressive symptoms over a 4-month period (Hewitt, Flett, & Ediger, 1996). There is also evidence when maladaptive components of perfectionism on the FMPS and HMPS are combined (i.e., sociallyprescribed perfectionism, CM, DA, PE, PC) that this composite score remains unchanged from pre- to post-treatment of depression (Cox & Enns, 2003). A series of prospective studies have also been conducted by Dunkley and colleagues using the 15 perfectionism related items from the Dysfunctional Attitudes Scale (DAS; Weissman & Beck, 1978), which has been referred to as self-criticism (DAS-SC). Dunkley, Sanislow, Grilo, and McGlashan (2006) examined a sample of 96 individuals with clinical depression and found that DAS-SC was related to depressive symptoms at 3-year follow-up, and mediators of this relationship were negative social support, negative social interactions and avoidant coping. In a subsequent study of 107 clinically depressed patients, Dunkley, Sanislow, Grilo, and McGlashan (2009) found again that negative perceptions of social support mediated the relationship between DAS-SC and depression over a four year period. There is also evidence that perfectionism is a vulnerability factor for mood swings in bipolar disorder. Alloy et al. (2009) demonstrated that DAS-SC scores significantly predicted the onset of manic and hypomanic episodes. Furthermore, Jones et al. (2005) found that a sample of individuals with bipolar disorder and a sample with unipolar recurrent depression had significantly higher scores on the achievement subscale of the DAS compared to controls. Perfectionism has been reported to have a strong and robust association with suicidal ideation and behaviour (Hewitt, Flett, Sherry, & Caelian, 2006). In clinical samples, socially-prescribed perfectionism has been linked to suicidal ideation (Hewitt, Flett, & Weber, 1994; Hewitt, Norton, Flett, Callander, & Cowan, 1998), and found to predict suicidal ideation in individuals hospitalised for selfharm (Rasmussen, O'Connor, & Brodie, 2008). In a prospective study of 515 adolescents, O'Connor, Rasmussen, and Hawton (2010) found that socially-prescribed perfectionism predicted depression and selfharm over a 6 month period. In another prospective study of a depressed inpatient sample, Beevers and Miller (2004) found perfectionism scores on the DAS-SC predicted higher suicidal ideation 6 months after discharge. 3.1.3. Anxiety disorders Perfectionism has a robust association with anxiety (Frost & DiBartolo, 2002). An interesting recent finding is that higher perfectionism on the FMPS has been linked to higher levels of cortisol response to stress (Wirtz et al., 2007). Each of the anxiety disorders will be reviewed in turn with the exception of Post Traumatic Stress Disorder and Generalised Anxiety Disorder, where there have been no studies examining perfectionism in clinical samples to the authors' knowledge. 3.1.3.1. Obsessive–compulsive disorder. Perfectionism has been linked to OCD in the literature for the past 100 years (Frost, Novara, & Rheaume, 2002). A number of items on the FMPS were taken from the Maudsley Obsessional Compulsive Inventory (MOCI; Hodgson & Rachman, 1977), and it has been suggested that the DA subscale is taken directly from a measure of OCD (Shafran & Mansell, 2001). Furthermore, perfectionism has been identified as one of the six key

cognitive factors in OCD by the Obsessive Compulsive Cognitions Working Group (OCCWG, 1997), hence the inclusion of the perfectionism subscale in the Obsessive–Beliefs Questionnaire (OBQ; OCCWG, 2001). There is evidence that clinical samples of individuals with OCD have significantly elevated perfectionism on the subscales of CM, PS and socially-prescribed perfectionism compared to controls as seen in Table 1 (Antony, Purdon, Huta, & Swinson, 1998; Buhlmann, Etcoff, & Wilhelm, 2008; Frost, Steketee, Cohn, & Griess, 1994; Frost & Steketee, 1997; Sassaroli et al., 2008). It has been suggested that perfectionism interferes with OCD patients' ability to engage in tasks of exposure and response prevention (Frost et al., 2002). Kyrios et al. (2007) found in a sample of 60 individuals who completed treatment for OCD that after controlling for pre-treatment symptoms, the perfectionism subscale of the OBQ was the only subscale of the measure to significantly predict treatment outcome. This finding is important as it provides indirect evidence of perfectionism as a maintaining mechanism in OCD. Furthermore, Chik, Whittal, and O'Neill (2008) found that DA predicted poorer response to group and individual treatment for OCD. 3.1.3.2. Social anxiety. One of the leading cognitive-behavioural theories of social anxiety includes the notion that perfectionism serves to prime socially anxious individuals to expect negative social interactions and that this results in social anxiety (Heimberg, Juster, Hope, & Mattia, 1995). In clinical samples, socially anxious individuals have significantly elevated perfectionism on CM and socially-prescribed perfectionism subscales compared to controls as seen in Table 1 (Antony et al., 1998; Juster et al., 1996; Saboonchi, Lundh, & Ost, 1999). Three studies have examined changes in perfectionism on the FMPS following CBT for social anxiety. In a sample of 24 patients with social anxiety, Lundh and Ost (2001) found significant improvements on all FMPS subscales. They also found that treatment non-responders had significantly higher perfectionism at the start of treatment. This suggests that perfectionism needs to be targeted directly, as higher levels of perfectionism were associated with not responding to CBT for social anxiety. Rosser, Issakidis, and Peters (2003) found decreases in CM after treatment for 61 patients receiving group CBT, however perfectionism did not predict treatment outcome over and above pre-treatment levels of social anxiety. In a larger sample of 107 patients with social anxiety undergoing group CBT, Ashbaugh and colleagues (2007) found significant decreases in the FMPS total and the subscales of CM and DA but not on the other subscales. Changes in CM and DA were found to predict level of social anxiety at the end of treatment, and in contrast to Rosser et al.'s findings, this was even after controlling for pre-treatment levels of social anxiety. This provides indirect evidence of perfectionism as a maintaining factor in social anxiety. 3.1.3.3. Panic disorder, worry and other anxiety disorders. Several studies have found that individuals with panic disorder (with or without agoraphobia) have significantly higher scores on CM, PS and socially-prescribed perfectionism as seen in Table 1 (Antony et al., 1998; Frost & Steketee, 1997; Iketani et al., 2002). Only one study has examined specific phobia, and found that perfectionism was not significantly elevated compared to controls (Antony et al., 1998). 3.1.4. Personality disorders There is overlap between the diagnosis of Obsessive–Compulsive Personality Disorder (OCPD) and perfectionism, given that one of the criteria for diagnosis is “perfectionism that interferes with task completion” (DSM-IV-TR, APA, 2000). However OCPD and perfectionism are not the same construct. As Shafran, Fairburn, and Cooper (2002) point out, other criteria such as hoarding and a miserly spending style do not fall within the construct of perfectionism, and that it would be possible to receive a diagnosis of OCPD and not have elevated perfectionism. Despite this, another criteria of OCPD is “rigidity”, which has been found to be related to perfectionism in

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clinical and non-clinical samples on the FMPS (Egan, Piek, Dyck, & Rees, 2007) and non-clinical samples on the HMPS (Ferrari & Mautz, 1997). In considering research that has examined perfectionism and OCPD, in a sample of 667 individuals, Halmi et al (2005) found that EDI-P scores were highest in AN and BN individuals who also had a diagnosis of OCPD, and that these scores were more closely related to OCPD than OCD. They concluded that the comorbid presentation of elevated perfectionism and OCPD may represent a core feature predisposing an individual to develop an eating disorder. Anderluh, Tchanturia, Rabe-Hesketh, and Treasure (2003) used retrospective recall of OCPD traits in childhood, and found that the odds ratio for developing an eating disorder were increased by 6.9 for each additional OCPD trait that was present compared to controls. Given that use of retrospective recall is problematic, longitudinal data is required to accurately understand the influence of childhood OCPD traits on the development of an eating disorder. However the results do suggest that perfectionism is closely linked to OCPD. There has been limited research of perfectionism in other personality disorders. As seen in Table 1, one study found a sample of 13 inpatients with Borderline Personality Disorder had significantly higher sociallyprescribed perfectionism compared to controls (Hewitt, Flett & Turnbull, 1994). Socially-prescribed perfectionism has also been found to be significantly higher in individuals with Narcissistic Personality Disorder (NPD) compared to those with Antisocial Personality Disorder and mood disorders (McCown & Carlson, 2004). In summary, while there is some empirical data to suggest OCPD and perfectionism are closely related, there is little evidence demonstrating the role of perfectionism in other personality disorders. 3.2. Perfectionism as an explanation for co-occurrence of disorders One of the distinct advantages of a transdiagnostic approach is that it may offer a parsimonious explanation for the high rates of cooccurrence between disorders. Harvey et al. (2004) propose that a transdiagnostic perspective can explain comorbidity which has reliably been demonstrated to be the norm (Kessler, Chiu, Demler, Merikangas, & Walters, 2005). They assert that comorbidity occurs because disorders share maintaining mechanisms (Harvey et al.). Based on the evidence presented, perfectionism is significantly elevated across multiple disorders and is a risk factor for multiple disorders. The data are consistent with perfectionism as an explanatory factor for co-occurrence among disorders. Further to this, Bieling, Summerfeldt, Israeli and Antony (2004) examined a sample of 345 patients with comorbid anxiety and mood disorders, and found that the number of comorbid diagnoses was correlated positively with the FMPS total score, CM, PC and DA and also with self-oriented and socially-prescribed perfectionism. Furthermore, when considering Maladaptive Evaluative Concerns (MEC = CM, PC, PE, PE and socially-prescribed perfectionism), MEC predicted higher levels of comorbidity even after controlling for current symptoms. The authors concluded that “…perfectionism is not associated with a single disorder or type of disorder, but may be an underlying factor across several disorders and categories of psychopathology” (p. 194). Following this, it was suggested that treating perfectionism may result in symptomatic relief across a number of domains. Thus, targeting perfectionism directly may be more beneficial in individuals with comorbid disorders than traditional single disorder based approaches which target maintaining factors of each disorder sequentially (Bieling et al., 2004).

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has been recognised as a significant maintaining factor in models of social phobia (Heimberg et al., 1995) and OCD (OCCWG, 1997). In their transdiagnostic theory of eating disorders, Fairburn, Cooper, and Shafran (2003) assert that ‘clinical perfectionism’ is one of four core mechanisms that maintain eating disorder pathology and if it was to be ameliorated then “...a potent additional network of maintaining mechanisms would be removed thereby facilitating change” (p. 516). Transdiagnostic CBT-E for eating disorders has been found to be effective (Fairburn et al., 2009). In addition, Shafran et al. (2002) have devised a model of “clinical perfectionism” that is designed to describe how perfectionism might maintain a variety of psychopathologies. Clinical perfectionism has been defined as “…the overdependence of self-evaluation on the determined pursuit of personally demanding, self-imposed, standards in at least one highly salient domain, despite adverse consequences” (p. 778). A recent revision of the model (Shafran, Egan, & Wade, 2010) as seen in Fig. 1 makes explicit the role that performance related behaviour, including performance checking (e.g., constantly comparing performance to others), avoidance, procrastination, and counterproductive behaviours (e.g., being over-thorough, checking) has in maintaining the cycle of clinical perfectionism. Preliminary data are consistent with the model. For example, individuals with perfectionism ‘raise the bar’ after achieving their goals (Kobori, Hayakawa, & Tanno, 2009) and dichotomous thinking, does predict significant variance in perfectionism (Egan et al., 2007). A qualitative study has also supported the maintaining factors of the model, for example finding themes of self-criticism following failure, rules, rigidity and avoidance amongst individuals with clinical perfectionism (Riley & Shafran, 2005). There is also data supporting that self-oriented and socially-prescribed perfectionism is associated with higher levels of shame and guilt following failure in a task, which supports predictions of the model (Stoeber, Kempe, & Keogh, 2008). The definition of clinical perfectionism has been seen as contentious by some authors, with Hewitt, Flett, Besser, Sherry, and McGee (2003) arguing that perfectionism should indeed be considered from a multidimensional perspective and cite support for this notion based on the findings of studies using the MPS scales. In response, Shafran, Cooper and Fairburn (2003) argued that their conceptualisation of clinical perfectionism was made from a clinical perspective, where theories and treatments have not focused on other-oriented factors. Shafran et al. (2003) claim “…a focus on the specific [self-oriented] mechanisms maintaining clinical perfectionism is more likely to permit psychopathology to be successfully treated” (p. 1218). Furthermore,

3.3. Perfectionism and cognitive-behavioural theories of maintenance of disorders Evidence for perfectionism being a transdiagnostic maintaining mechanism can be seen by the fact that it has been included in numerous cognitive-behavioural models of disorders. Perfectionism

Fig. 1. The revised cognitive-behavioural model of clinical perfectionism, reproduced from Shafran, Egan, and Wade (2010).

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criticisms of the model (e.g., Dunkley, Blankstein, Masheb, & Grilo, 2006) are based on the notion that Shafran et al (2002) were stating that personal standards were maladaptive. However this is not the case, rather the underlying idea in the model of clinical perfectionism was that there was nothing maladaptive in striving for excellence in itself, rather it is when someone bases their sense of self-worth almost exclusively on striving for standards, and concern over mistakes in meeting these standards, when perfectionism becomes a “clinical” problem. Thus, findings in the literature supporting two main areas of perfectionism involving Personal Standards and Maladaptive Evaluative Concerns (Dunkley, Blankstein, et al., 2006), are in line with the model of clinical perfectionism, where the emphasis is on the maladaptive nature of basing self-evaluation on striving, and concern over mistakes in striving. Further empirical support for the definition of clinical perfectionism is shown in a study using the measure of clinical perfectionism (Clinical Perfectionism Questionnaire; CPQ, Fairburn, Cooper, & Shafran, unpublished, cited in Riley, Lee, Cooper, & Fairburn, 2007) associated with the model and comparing it to the MPS in an eating disorder population (Steele, O'Shea, Murdock, & Wade, in press). Clinical perfectionism was found to have a unique relationship with depression and to better explain overevaluation of weight and shape. While having a model that can account for how the processes of maladaptive evaluative concerns and self-worth being contingent on meeting standards is maintained can help to guide assessment and treatment, further examination of the model using relevant measures is required before firm conclusions can be made as to the utility of the model for clinical practice. 3.4. Treatment of perfectionism If perfectionism is a transdiagnostic process one would predict that high levels of perfectionism would impede treatment across different psychopathologies and that treating perfectionism should reduce a variety of psychopathologies. Evidence supporting each of these predictions is examined in turn. 3.4.1. Perfectionism has a negative impact on treatment outcome Data indicates that perfectionism can impede patients' ability to engage with treatment successfully. Five studies have examined the impact of perfectionism on treatment outcome in depression using data from the well known National Institute of Mental Health Treatment of Depression Collaborative Research Program study that compared interpersonal psychotherapy, CBT and anti-depressants (Elkin et al., 1989). Perfectionism as measured by DAS-SC was found to predict poorer response to treatment in all groups at post treatment (Blatt, Quinlan, Pilkonis, & Shea, 1995) and 18 month follow-up (Blatt, Zuroff, Bondi, Sanislow, & Pilkonis, 1998). One mediator of this poor treatment response was that perfectionism interfered with the therapeutic alliance, particularly in the second half of treatment (Zuroff et al., 2000). Further analysis also revealed another mediator is the quality of social networks, where pre-treatment levels of perfectionism predict poorer social networks which in turn predict poorer treatment outcome (Shahar, Blatt, Zuroff, Krupnick, & Sotsky, 2004). Finally, Blatt and Zuroff (2005) found that higher levels of perfectionism at both pre and post treatment predicted poorer ability to cope with life stress 18 months after treatment. In eating disorders, EDI-P scores have been associated with poorer prognosis after admission for AN (Bizuel, Sadowsky, & Riguad, 2001), to be significantly lower at pre-treatment amongst individuals in remission in a mixed eating disorder sample (Santonastaso, Friederici, & Favoro, 1999), and higher levels of EDI-P scores in AN have been associated with treatment drop-out (Sutandar-Pinnock, Carter, Olmsted, & Kaplan, 2003). Furthermore, perfectionism remains elevated post treatment of eating disorders (Bastiani et al., 1995; Lilenfeld et al., 2000; Nilsson et al., 2008; Pla & Toro, 1999; Srinivasagam et al., 1995).

However perfectionism was not found to predict treatment outcome or remission in BN in one study (Mussell et al., 2000) but a recent study suggests that higher levels of CM at baseline resulted in less reduction on the EDE (Fairburn & Cooper, 1993) global score when treating BN using guided self help (Steele, Bergin, & Wade, in press). A useful question to consider is if perfectionism is indeed a transdiagnostic process, then how does it interact with the maintenance processes of specific disorders to make them less amenable to treatment? Shafran et al (2002) argued that ‘an interaction between clinical perfectionism and treatment response will be seen whenever the domain in which perfectionism is expressed overlaps with the domain affected by the psychiatric disorder’ (p. 783). To illustrate how perfectionism can interact with maintaining factors in disorder specific models, consider the case of Harry. Harry is a 38 year old married salesman with two children who meets diagnoses of social phobia, obsessive–compulsive disorder and depression. He worries about his performance in meetings at work and coming across perfectly to others, so pays attention in detail to himself, what he is saying and rehearses conversations. Harry also has significant checking rituals, and will check doors, locks and the oven multiple times as he feels responsible for harm coming to his family, but checks again and again as he has a thought that he must check perfectly or harm will occur. Harry also thinks that he is not performing well at work and that he must achieve his excessively high standards for sales to be good enough, and feels like he is failing as a result. If we consider the case of Harry, we can see that perfectionism is a transdiagnostic process that is occurring across the specific diagnoses that he meets. Mansell, Watkins, Harvey, and Shafran (2008) suggest that an individual's current concerns determine how a transdiagnostic process is manifested as symptoms, and in the case of Harry, his concerns centre on social performance, intrusive thoughts of harm coming to others and failure. Perfectionism then interacts with the known maintaining mechanisms from cognitive models of social anxiety, OCD and depression, as seen in the case conceptualisation in Fig. 2. In this case it is hypothesised that perfectionism drives the other maintaining factors. Harry has perfectionist beliefs that he must appear perfect in social situations, which interacts with the maintaining mechanism of social anxiety of self-focused attention (Clark & Wells, 1995), which in turn further reinforces perfectionist beliefs in regards to social performance. Harry also has beliefs that he must check perfectly, which interacts with the maintaining mechanism of responsibility in OCD (Salkovskis, 1985), which further reinforces his beliefs he must check perfectly in order to prevent harm. Finally, Harry bases his sense of worth as a person on how well he does at work in reaching excessive sales targets, and when he feels he is not meeting up to his own standards, engages in negative evaluative thoughts about himself as a failure (Beck, Rush, Shaw, & Emery, 1979) which further reinforces his beliefs he must achieve to be worthwhile.

Fig. 2. Case conceptualisation demonstrating the transdiagnostic role of perfectionism and interaction with maintaining factors of specific disorders.

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3.4.2. Outcome data for treatment of perfectionism Evidence for perfectionism as a transdiagnostic maintaining mechanism also comes from data indicating that treatment of perfectionism results in reduction of symptoms across clinical disorders. Pleva and Wade (2007) used both guided and pure self help CBT for perfectionism and found it resulted in significant reductions in perfectionism, anxiety and depressive symptoms. In their sample, 30% of people showed clinically significant decreases in obsessionality and depression, and 15% clinically significant decreases in anxiety. However generalisations about treatment efficacy cannot be made from this study involving a non-clinical population. There have been a small number of controlled studies demonstrating the efficacy of treatment of perfectionism in clinical anxiety and depression. Glover, Brown, Fairburn, and Shafran (2007) used a multiple baseline single case experimental design series with nine individuals with either an anxiety disorder or depression. They found that 10 sessions of CBT for clinical perfectionism resulted in clinically significant improvement on the CPQ (Fairburn et al., unpublished, in Riley et al., 2007) and both Multidimensional Perfectionism Scales, and three participants experienced clinically significant reductions on the Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996), although there were no significant reductions in anxiety. Egan and Hine (2008), also found significant reductions in FMPS total scores in a single case experimental design series following an eight session treatment for clinical perfectionism in individuals with anxiety and depression. Riley et al. (2007) conducted a randomised controlled trial of 10 sessions of CBT for clinical perfectionism in 20 participants with anxiety and/or depression who were randomly allocated to either immediate or waitlist treatment. There were clinically significant improvements for 15 participants in clinical perfectionism on the CPQ (Fairburn et al., unpublished, in Riley et al., 2007) and an unpublished clinical perfectionism interview. There were also significant reductions on the Multidimensional Perfectionism Scales (MPS), although there was no significant difference between the waitlist and immediate treatment group. In addition to these reductions in perfectionism, they also found significant reductions in scores on the BDI-II, Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988), and Brief Symptom Inventory (BSI; Derogatis & Melisaratos, 1983) at post treatment and eight week follow-up. When considering diagnostic status, the number of participants meeting criteria for an anxiety disorder or depression halved after treatment, while no change in the number of participants meeting diagnoses was seen in the wait list participants. Steele and Wade (2008) examined treatment of perfectionism in a sample of 42 patients with bulimia nervosa or EDNOS. The treatment involved 8 sessions of guided self help over 6 weeks and three conditions were compared; CBT for perfectionism, CBT for BN and placebo, consisting of ‘dismantled mindfulness’. Whilst there were no significant differences between groups, CBT for perfectionism did produce significant decreases of large effect size in bulimic behaviours as well as anxiety and depression. When effect sizes are compared between the treatments, CBT for perfectionism appeared to have larger effects on non-targeted psychopathology of anxiety and depression, whilst still achieving significant reductions in bulimic symptoms. This data therefore provides further support for perfectionism as a transdiagnostic process. Furthermore, it suggests the interesting notion that by reducing perfectionism, which is a known risk and maintaining factor of BN, then BN can be effectively reduced as well as comorbid anxiety and depression, without even focusing on these symptoms in treatment. A final interesting finding in perfectionism and eating disorders, was a study by Wilksch, Durbridge, and Wade (2008) examining the impact of reduction of perfectionism in adolescent females. They found that a program targeting perfectionism had greater benefit for high eating disorder risk participants, which was defined as the participants with high shape and weight concern, compared to a media literacy program and control. This is a promising finding and suggests that targeting

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perfectionism in adolescent females could be a potentially useful way to reduce eating disorders in those participants who are at risk, although longitudinal research is required to determine the long term effects of this program in the prevention of eating disorders. In terms of effect sizes, treatment of perfectionism has produced predominately large effects, as defined by Cohen's (1988) criteria. Treatment of perfectionism has been found to result in large effects for eating disorder symptoms on the global scale of the EDE (d=1.73) and depression (d=0.86) (Steele & Wade, 2008). Large effects have also been found for perfectionism as measured by CM (d=1.09) (Steele & Wade, 2008) and clinical perfectionism on the CPE (d=1.83) and CPQ (d=1.31) (Riley et al., 2007). Medium effects have been found for anxiety (d=0.69) (Steele & Wade, 2008) and small effects on perfectionism on the subscales of PS (d=0.39) (Steele & Wade, 2008), (d=0.44) (Wilksch et al., 2008) and CM (d=0.45) (Wilksch et al., 2008). Although the number of studies to date examining CBT for perfectionism is relatively small, and as yet there have been no studies comparing other active treatments in an RCT, the data is promising in showing that perfectionism can be reduced significantly through treatment and that this reduces symptoms across anxiety disorders, depression and eating disorders. This represents evidence for perfectionism being a transdiagnostic process, given that the particular symptoms of the disorder were found to be significantly reduced after treating perfectionism, even though there was no focus on the symptoms of the disorder in treatment (Egan & Hine, 2008; Glover et al., 2007; Riley et al., 2007; Steele & Wade, 2008). 4. Clinical implications 4.1. Assessment and individualised case conceptualisation It is suggested that clinicians routinely assess for perfectionism, through the use of the MPS scales and also by focusing on issues identified in the model of clinical perfectionism shown in Fig. 1. This would entail that clinicians ask about the degree to which their patient bases their sense of self-worth on striving and achievement. If the patient judges their self-worth predominately on how well they achieve their personal standards, then it is important to further assess for the maintaining factors of clinical perfectionism. These are outlined in the revised cognitive-behavioural model of perfectionism in Fig. 1. This involves asking the client what areas of their life they have high standards in and the impact that striving has on their life. Examples of their reaction to failure to meet a goal, whether they feel satisfied after reaching a goal, and if they re-set their standards higher after meeting a goal or avoid trying to meet a goal because of fear of failure (i.e., procrastination) are explored. Cognitive biases are assessed by determining their dichotomous rules for achievement, and how they react to breaking their rules. Examples to determine whether they discount their successes and notice their failures are detailed. To assess self-criticism, a recent example of their cognitions when they made a mistake is explored. Counter-productive behaviours are assessed through asking the patient what they avoid and delay in regards to performance, examples of how they compare their performance to others, and if they seek reassurance from others about their performance. This information is used to guide the development of a collaborative, individualised, formulation diagram for the patient based on their examples, following the diagram in Fig. 1. 4.2. Directly target perfectionism early in treatment One of the main clinical implications resulting from this review is that if a clinician identifies that perfectionism is elevated in their patient and that it is substantially interfering with their quality of life, then it should be focused on specifically and addressed adequately and directly in treatment. This may involve directly targeting perfectionism as the primary issue, particularly if it appears to be a barrier to change with an

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established intervention. Techniques to treat clinical perfectionism have been described in detail elsewhere (Shafran et al., 2010). Briefly, strategies include increasing motivation to change and self-monitoring of the maintaining mechanisms in the clinical perfectionism model. To address counter-productive behaviours and rigid rules, surveys and behavioural experiments are utilised. Cognitive biases including dichotomous thinking and selective attention are addressed through thought records, behavioural experiments and continuums. Selfcriticism is addressed through thought diaries and utilising a compassionate rather than critical voice. Finally, broadening self-evaluation is achieved through pie charts to consider other aspects through which a patient can evaluate their self-worth instead of predominately by achievement. The aim of treatment is not to remove striving for personal standards or lowering standards, rather to remove self-evaluation being exclusively based on meeting personal standards, and criticism when the standards are not met. This may result in altered standards that contribute to a better quality of life. It has been argued that it is adaptive to reduce energy when a goal cannot be met, and to relinquish goals if they are unattainable, as continued commitment to a goal that is not able to be met leads to distress (Carver, 2004; Johnson, Carver, & Fulford, 2010). Consequently, we might consider someone to be recovered from clinical perfectionism when they are able to still strive towards goals that are attainable, to not judge themselves adversely if the goals are not met, to invest energy in goals that are not performance related, and to be able to shift focus and effort away from unattainable goals. Based on Perceptual Control Theory, Mansell (2005) has described how distress is created by individuals having a conflict between goals, for example a striving towards and avoidance of goals at the same time (see also Mansell, Harvey, Watkins, & Shafran, 2009). Within this model of normal goal striving, we may consider an individual to have recovered from clinical perfectionism if they are able to resolve the conflict between their goal states of striving towards and avoidance. Given that one of the advantages of adopting transdiagnostic treatments should be that it is more practical and parsimonious than applying several disorder specific interventions (Shafran, McManus, & Lee, 2008), one would predict that an early focus on perfectionism in treatment would obviate the need to tackle specific psychopathology later in therapy. This is an empirical question that requires further investigation across different disorders in future research. 5. Summary Evidence has been reviewed for the argument that perfectionism contributes to the aetiology and maintenance of multiple psychiatric disorders and it can therefore be considered as a transdiagnostic process. Substantial evidence showing that perfectionism is elevated in anxiety disorders, depression and eating disorders was reviewed. Data suggesting that perfectionism explains comorbidity across disorders were also presented. We argued that the rationale for addressing perfectionism across disorders is based on the fact that it is elevated across disorders, that it is a transdiagnostic risk and maintaining process, and if perfectionism is not targeted in treatment, then it leads to poorer outcomes. Evidence of the efficacy of targeting perfectionism across disorders was presented, and we suggested that clinicians should routinely assess for and address this transdiagnostic process when it is present. It is hoped that such a focus may help to improve the efficacy of treatment for a wide range of problems, and potentially reduce a potent risk and maintaining factor for many psychological disorders. References Alloy, L. B., Abramson, L. Y., Walshaw, P. D., Gerstein, R. K., Keyser, J. D., Whitehouse, W. G., & Harmon-Jones, E. (2009). Behavioural approach system (BAS)—Relevant cognitive styles and bipolar spectrum disorders: Concurrent and prospective associations. Journal of Abnormal Psychology, 118, 459−471.

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