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Dimensions of perfectionism and perfectionistic self-presentation in social phobia
Asian Journal of Psychiatry 3 (2010) 216–221
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Dimensions of perfectionism and perfectionistic self-presentation in social phobia Mansi Jain, Paulomi M. Sudhir * Department of Mental Health and Social Psychology, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bangalore 560029, Karnataka, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 18 October 2009 Received in revised form 14 August 2010 Accepted 19 August 2010
In a cross sectional study we examined the dimensions of perfectionism and perfectionistic selfpresentation in patients with social phobia. We also examined associations between perfectionism and self-report of anxiety and depression with fear of negative evaluation. Thirty patients with a diagnosis of social phobia and 30 community volunteers completed two measures of trait perfectionism, fear of negative evaluation and measures of anxiety and depression. The clinical sample had overall higher levels of perfectionism and had greater fear of negative evaluation, social anxiety, trait anxiety and depression than the community sample. The clinical sample had significantly higher concern over mistakes, doubts over actions, parental criticism (F-MPS, Frost et al., 1990) and scored higher for nondisplay of imperfection on the Perfectionistic Self Presentation Scale (PSPS; Hewitt et al., 2003). The two groups did not differ on other dimensions of perfectionism, or on both measures of perfectionism. The two measures of perfectionism were positively correlated. There was a significant correlation between trait perfectionism and Brief Fear of Negative Evaluation scale (BFNE). The paper discusses the importance of examining perfectionism in social phobia. ß 2010 Elsevier B.V. All rights reserved.
Keywords: Perfectionism Social phobia Perfectionistic self-presentation Social anxiety
1. Introduction The hallmark of social phobia (SP) is a marked fear of social or performance situations, fear of scrutiny and negative evaluation and the avoidance of situations in which these fears are triggered (APA, 1994). It is the third most common psychiatric disorder (Kessler et al., 1994) with a poor rate of spontaneous remission (Bruce et al., 2005). The lifetime prevalence of SP ranges from 2.4% to 13%. Co-morbidity rates for SP are high and include other anxiety disorders, mood disorders, substance dependence and bulimia nervosa (Federoff and Taylor, 2001; Kessler et al., 1999). The onset of SP is typically early although people with SP seek treatment much later when they experience impairment in social and occupational roles. Persons with SP are excessively concerned with possible errors they may make in social situations and predict rejection or loss of status as a result of their behaviours. Fear of negative evaluation (FNE) is a core feature of SP and is associated with heightened negative affect and interpersonal awareness (Beck et al., 1985; Harb et al., 2002). It reflects the tendency to focus selectively on evidence of failure and to be self-critical. In order to avoid possible failure, persons with SP set unrealistically high standards for themselves (Clark and Wells, 1995; Rapee and Heimberg, 1997). These personally demanding standards are motivated largely by a
* Corresponding author. Tel.: +91 080 26995180; fax: +91 080 26564830. E-mail address: [email protected] (P.M. Sudhir). 1876-2018/$ – see front matter ß 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.ajp.2010.08.006
fear of failure and need to impress, which in turn leads to avoidance and hyper vigilance (Eysenck, 1997; Hamachek, 1978). Alden et al. (1994) suggest that persons with SP may actually set lower standards than their actual potential and may continually underestimate themselves. Clinical evidence suggests that perfectionism is relevant to SP (Heimberg, 1996; Juster et al., 1996). Perfectionism refers to the desire to achieve the highest standards of performance, in combination with unduly critical evaluations of one’s performance (Frost et al., 1990). It is a multidimensional personality trait, with both adaptive and maladaptive aspects (Hewitt and Flett, 1991). The first multidimensional measure of perfectionism was developed by Frost et al. (1990) and consists of six dimensions that include concern over mistakes, doubts about actions, parental expectations, personal standards, parental criticism, and organization. Perfectionism has been identified as a vulnerability factor in the development of depression (Chang and Sanna, 2001; Hewitt and Flett, 1991; Hewitt et al., 1996), and other psychological problems such as hopelessness, suicidality, (Hewitt et al., 1998; O’Connor and O’Connor, 2003), eating disorders (Minarik and Ahrens, 1996), obsessive–compulsive disorder and other anxiety disorders (Antony et al., 1998). Perfectionistic self-presentation (PSP) is yet another dimension of perfectionism that includes an interpersonal aspect (Hewitt et al., 2003). PSP includes an excessive need to appear perfect in the eyes of others, with distinct, stable dimensions of, perfectionistic self–promotion i.e., proactively promoting a perfect image, nondisclosure of imperfection i.e., concern over verbal disclosures of
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The MINI (the mini-international neuropsychiatric interview M.I.N.I; Sheehan et al., 1998) was used to confirm diagnosis of SP. The community sample was screened both on the General Health Questionnaire-12 (GHQ-12; Goldberg and Williams, 1988) and the MINI. The average age of participants in the two groups was 28.90 years (SD = 8.256), and 28.73 years (SD 7.334) in the clinical and community sample respectively. A majority of the participants in both groups were male (93% and 80%) and single (70% and 76.7%). Experts at the department of mental health and social psychology, NIMHANS reviewed the study for ethical considerations. A written informed consent was obtained from the participants. The order of administration was kept constant.
imperfection and non-display of imperfection i.e., concern over behavioural displays of imperfection (Hewitt et al., 2003). Although the two aspects of trait perfectionism overlap to a certain degree, they are considered to be conceptually distinct from each other and both function as vulnerabilities in the development of emotional problems (Dunkley et al., 2003). Research suggests that perfectionism is much more likely to develop in families where parental anxiety concerning social interactions is high and need for others’ approval is excessively emphasized (Bruch et al., 1989; Juster et al., 1996). Asian American samples report higher personal standards, strict parental control, lack of open communication with parents, and higher educational expectations and emotional alienation than their Caucasian peers (Kawamura et al., 2002). Patients with SP report a higher concern over mistakes, doubts of one’s action and parental criticism than community controls and patients with panic disorder (Juster et al., 1996; Saboonchi et al., 1999). However, this has been relatively less researched in comparison to other psychiatric conditions and there are no cross-cultural comparisons. The clinical implications of perfectionism and its role in maintenance of anxiety disorders and SP in particular, have received relatively less attention. High levels of clinical perfectionism that includes personally demanding standards with selfcriticality hampers the progress of therapy and maintains negative affect through excessive self-criticality (Shafran et al., 2002). Perfectionism and interpersonal aspects of perfectionism have been previously studied in western populations and largely in non-clinical samples and limit generalization of findings to other populations (Hewitt et al., 2003; Juster et al., 1996). In the Asian Indian setting, perfectionism has been explored in a few recent studies on university samples (Slaney et al., 2000). The cross-cultural aspects of perfectionism have been inadequately addressed in clinical samples. The need to examine cognitive features such as FNE in association with trait perfectionism has also been emphasized (Antony et al., 1998). The purpose of this study was to examine the dimensions of perfectionism patients with SP in an Asian Indian setting. We also examined associations between trait perfectionism and anxiety, depression, and FNE. Perfectionism, particularly its interpersonal aspects, is likely to be influenced by socio-cultural factors. To our knowledge there are no published studies examining trait perfectionism in a clinical sample in this cultural context. The findings of such a study would contribute to a cross-cultural understanding of perfectionism in SP.
Frost’s multidimensional perfectionism scale (F-MPS; Frost et al., 1990) is a 35 item questionnaire with six dimensions, namely concern over mistakes (CM), personal standards (PS), parental expectation (PE), parental criticism (PC), doubts about actions (DA) and organization (O). The reliability of the total perfectionism scale is 0.90. Internal consistency of the F-MPS ranges from 0.77 to 0.93. The perfectionistic self-presentation scale (PSPS; Hewitt et al., 2003) is a 27-item measure with three subscales: perfectionistic self-promotion, non-display of Imperfection and non-disclosure of Imperfection. Higher scores indicate greater levels of need for perfection. Coefficient alpha for PSPS subscales range from .75 to .90 (Hewitt et al., 2003). Brief fear of negative evaluation scale (BFNE; Leary, 1983) is a 12-item measure that assesses concerns over negative interpersonal evaluation, based upon the original FNE (Watson and Friend, 1969). It correlates highly (r = .96) with the original FNE and has demonstrated good test-retest reliability and internal consistency (Leary, 1983). Liebowitz social anxiety scale (LSAS; Liebowitz, 1987) measures fear and avoidance of social interactions and performance situations. LSAS has adequate psychometric properties. It was used as self-report of social anxiety in this study. State–trait anxiety inventory (STAI; Spielberger et al., 1983) is a 20 item self-report measure with two forms that assess state and trait anxiety. It is a widely used measure of anxiety with adequate psychometric properties. Beck depression inventory II: (BDI II, Beck et al., 1996) was used to assess severity of depression. Descriptive statistics, t-test, correlations and partial correlations were used to analyse the data obtained (Table 1).
2. Methods
3. Results
2.1. Sample and design
Sixty seven percent (67%) of the clinical sample had a primary diagnosis of SP, 33% had a diagnosis of SP with anxious avoidant personality disorder (AAPD). Research indicates that 60% of patients with SP also receive a diagnosis of AAPD (Heimberg, 1996). In addition, two patients had co-morbid depression that included recurrent depressive disorder and dysthymia. As expected the clinical sample scored higher than community controls (Table 2) on LSAS, (Mean = 72.53; t = 8.31, p < 001), state (Mean = 41.97; t = 3.29, p < .05) and trait anxiety (Mean = 54.60, t = 7.40, p < .001) indicating presence of significant anxiety symptoms at the time of assessment. The clinical sample had a mean BDI score of 17 (11.20), indicating mild severity of depressive symptoms. This was significantly higher than that of the community sample (t = 4.49, p < .001). The average duration of illness was 10.6 years (6.62), with a range of 3–28 years indicating a chronic course. Patients with SP had a significantly higher total score on F-MPS (Table 2; Mean = 92.4; t = 2.78, p < .001) than the community
Thirty patients with an ICD 10 (WHO, 1992) diagnosis of SP (F 40.1) and 30 community volunteers formed the sample for the study. A cross sectional, case control design was adopted. The clinical sample consisted of patients with a primary diagnosis of SP and was selected from the psychiatric outpatient services of NIMHANS, Bangalore. Patients with co-morbid anxious avoidant personality disorder (ICD 10; AAPD; F-60.0) and depressive disorders, other than severe depressive disorder, (F-32.2 and 32.3) were also included. The community sample was recruited using the snowball technique. Exclusion criteria were a diagnosis of psychosis, bipolar affective disorder, severe depressive episode with psychotic symptoms, other anxiety disorders, Axis II disorders other than anxious avoidant personality disorder, current psychoactive substance abuse, organic and neurological disorders and major physical illnesses or structured psychological intervention in the last 12 months for SP.
2.2. Measures
M. Jain, P.M. Sudhir / Asian Journal of Psychiatry 3 (2010) 216–221
218 Table 1 Socio-demographic description of the sample. Category
Clinical sample (n = 30)
Community control (n = 30)
28.90 8.256
28.73 7.334
Age Mean SD Category
Clinical sample (n = 30)
Community Control (n = 30)
n
%
n
%
Male Female
28 2
93.3% 6.7%
24 6
80.0% 20.0%
Graduate Post Graduate
17 7
56.7% 23.3%
7 17
23.3% 56.7%
Never married Married
21 9
70.0% 30.0%
23 7
76.7% 23.3%
Student Employed Unemployed
8 19
26.7% 63.3%
13 16
43.3% 53.3%
Hindu Others
24 6
80.0% 20.0%
25 5
83.3% 16.6%
Present Absent
10 20
33.3% 66.7%
8 22
26.7% 73.3%
Sex
Education
Marital status
Occupation
Religion
Family history
sample. When the two groups were compared on specific dimensions of perfectionism, the clinical sample had higher scores on CM (Mean = 28.8, SD = 7.2; t = 3.39, p < 0.001), PC (Mean = 12, SD = 3.1, t = 3.62, p < 0.001) and DA (Mean = 13.4, SD = 3.5, t = 4.14, p < 0.001). There were no differences on the other dimensions of the F-MPS. The community sample scored higher on PE although the difference was not statistically significant. Patients with SP reported greater FNE (Mean = 40.83; t = 6.07, p < .05). When we compared the two groups (Table 2) on the perfectionistic self-presentation scale (PSPS), the clinical group
reported a significantly higher need to appear perfect (Mean = 129.63; t = 2.84, p < .05) before others. The clinical group had a higher need for non–display of imperfection (Mean = 51.27; t = 3.74, p < 05). There were no differences between the two groups on PSP and non-disclosure of imperfection. Items on nondisplay of imperfection include, ‘‘Errors are much worse if they are made in public rather than in private’’ and ‘‘It would be awful if I made a fool of myself in front of others.’’ There was a significant positive association between FNE and PSPS (Table 3 r = .478, p < 01) and overall perfectionism on the F-MPS (Table 3; r = .398, p < .05) indicating that trait perfectionism is associated with cognitive aspects of SP. Perfectionism (F-MPS) and social anxiety were significantly correlated in the clinical sample (r = .440, p < .05). There was a modest association between PSPS and LSAS and state–trait anxiety (r = .332; p < .07 and 0.359; p < 0.05). Partial correlations controlling for the influence of mood using the BDI was carried out. The association between F-MPS and social anxiety continued to remain significant after controlling for depression (r = .415, p < .05) indicating a unique relationship between perfectionism and social anxiety. Total score on the F-MPS was significantly associated with LSAS, but not with STAI. There were no significant correlations between PSPS and the measures of anxiety and depression. PSPS was significantly associated with FNE, indicating that PSPS may be more specific to interpersonal aspects of perfectionism. CM was significantly associated with trait anxiety (r = .400; p < 0.05) and depression (r = .474; p < 0.01). DA was significantly associated with LSA-Fear, and depression (r = .432; p < 0.05). PS was significantly correlated with LSAS- Fear (r = .438; p < .0.05), but not with other measures of anxiety or depression. PC was significantly correlated with depression (r = .455; p < 0.05) but not with measures of anxiety. PE and organization did not correlate significantly with any of the measures of anxiety or depression. 4. Discussion In the present study we examined the dimensions of perfectionism and perfectionistic self-presentation in patients with SP and explored the association of trait perfectionism with FNE measures of anxiety and depression. Despite clinical evidence of perfectionism in patients with SP, there has been a paucity of
Table 2 Comparison of scores on measures of perfectionism (FMPS and PSPS) and brief fear of negative evaluation (BFNE), anxiety (LSAS and STAI) and depression (BDI). Measures
Clinical (n = 30) Mean
Frost’s multidimensional perfectionism scale Concern over mistakes Personal standards Parental expectations Parental criticism Doubt over Action Organization Total Perfectionistic self-presentation scale Perfectionistic self-promotion Non-display of imperfection Non-disclosure of imperfection Total Brief fear of negative evaluation Liebowitz social anxiety scale State–trait anxiety inventory – ST State–trait anxiety inventory – TR Beck’s depression inventory * **
p < .05. p < .01.
28.8 23.6 14.5 12 13.4 22.6 92.4
Control (n = 30) SD 7.2 6.9 4.2 3.1 3.5 4.3 19.2
Mean 22.1 22.3 16.2 9.4 9.9 23.2 79.9
t-values
Sig
SD 7.2 5.3 3.9 2.5 3.1 4.3 15.5
3.99** 0.842 1.6 3.62* 4.14** 0.507 2.78*
<0.001 0.404 0.119 0.001 <0.001 0.614 0.007
49.63 51.27 28.73 129.63
12.42 10.94 6.51 23.42
43.73 41.7 27.4 112.83
11.3 8.74 6.78 22.4
1.93 3.74** 0.777 2.84*
0.059 <0.001 0.44 0.006
40.83 72.53 41.97 54.60 17.10
8.00 20.88 9.00 8.26 11.20
29.67 29.40 34.17 38.20 6.53
6.14 19.28 9.37 8.89 6.37
6.07** 8.31** 3.29* 7.40** 4.49**
<0.001 <0.001 .002 <0.001 <0.001
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Table 3 Correlations between measures of perfectionism (FMPS and PSPS) and brief fear of negative evaluation (BFNE), anxiety (LSAS and STAI). Measures
Brief fear of negative evaluation Leibowitz social anxiety scale STAI-state STAI- trait * **
Frost multidimensional perfectionism scale (FMPS)
Perfectionistic self-presentation scale (PSPS)
Clinical (n = 30)
Community (n = 30)
Clinical (n = 30)
r
Sig
r
Sig
r
Sig
Community (n = 30) r
Sig
.398* .440* 0.285 0.35
0.029 0.015 0.127 0.058
0.339 0.005 0.104 0.176
0.067 0.981 0.586 0.351
0.476** 0.332 0.197 0.359
0.008 0.073 0.297 0.051
0.185 0.081 0.131 0.007
0.328 0.669 0.492 0.973
p < .05. p < .01.
studies examining this area. The few studies that are available have been from western settings. Our sample was typical of patients seeking treatment for SP. A majority of the clinical sample comprised of young adults, males, belonging to an urban middle socioeconomic background, educated, with a chronic course and mild depressive symptoms. They reported depressive symptoms that were of mild severity but varied across the group. Higher rates of depression in SP arise possibly as a result of social isolation and low self-esteem (Stein et al., 1990). There were expected differences between the two groups on the overall scores of both measures of perfectionism and symptom measures. The clinical sample had higher concern over mistakes, doubts over one’s actions and parental criticism than the community sample. CM is a tendency towards critical self-evaluation, to equate mistakes with failure and expect negative responses from others (Frost et al., 1990; Rosser et al., 2003). Individuals with SP fail to appreciate their performance and experience self-doubt regarding their decisions (Juster et al., 1996). CM was significantly associated with both BFNE and non-display of imperfection, both of which measure excessive concern over failure and mistakes, as well as a need to conceal this. Rosser et al. (2003) suggest that there is an overlap between CM and FNE. The clinical sample endorsed a greater tendency to doubt the quality of one’s performance (Frost et al., 1990). This is manifested in the person’s attempt to make the right response in social interactions (Juster et al., 1996). DA is also reported to be high in patients with Obsessive Compulsive Disorder OCD (Antony et al., 1998) however, it is possible that concern in patients with SP is greater with regard to social interactions. Only certain dimensions of perfectionism were significantly correlated with anxiety and depression, indicating the need to examine and address these maladaptive dimensions more closely in future studies. The scores of the sample in our study were higher on all dimensions of F-MPS except personal standards, as compared to western samples (Juster et al., 1996). We used the ICD10 criteria in our study as this is currently in use in the setting of our study. Most studies reported have used the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria to identify SP. More studies are required to examine crosscultural variations in order to draw definitive conclusions across samples. The community sample reported higher PS. PS is considered to be an adaptive aspect of perfectionism, related to efficacy (Lundh, 2004; Stoeber et al., 2007). High levels of PS may become dysfunctional only when there is a large discrepancy between one’s standards and the perceived ability (Alden et al., 1994). The two groups did not differ on PE. PE is significantly associated with personal standards, a measure of self-expectations, (Frost et al., 1990) and parents of patients with SP rely more on the use of shame as a disciplinary technique indicative of greater criticism (Bruch et al., 1989; Bruch and Heimberg, 1994). Patients with SP reported greater PC while community participants reported greater PE, but not PC. These findings are
consistent with previous research on patients with SP (Juster et al., 1996). This further emphasizes the relevance of early learning patterns and experiences in the development of perfectionism. Perfectionism is hypothesized to develop more readily in families with overly critical and demanding parents (Bruch et al., 1989; Lieb et al., 2000). Our findings thus lend cross-cultural validity to the existing literature on perfectionism in SP. Studies carried out on Asian American participants indicate presence of greater harshness, criticism and concern over social behaviours and academic achievement in Asian American parents than in western counterparts. However, these findings are based on Asians living in western societies (Kawamura et al., 2002). Slaney et al. (2000) found that Asian Indian students who rated themselves higher on perfectionism had higher PS and order and reported great concerns over interpersonal relations. The key difference between Indian and American students was lower anxiety in Indian students. Dysfunctional cognitions in social anxiety are centered on social interactions, perceptions of self as seen by scrutiny by others (Clark and Wells, 1995). Previous researchers have examined public self-consciousness in SP but found it to be part of social anxiety and not perfectionism (Saboonchi et al., 1999). Self-presentation is described as a maladaptive interpersonal style and is identified as an aspect of perfectionism (Hewitt et al., 2003). Non-display of imperfection is the extreme concern over behaviourally demonstrating imperfection. It is usually expressed in avoidance of situations, where such shortcomings might be obvious and in efforts to conceal them (Hewitt et al., 2008; Higgins, 1998; Leary, 1993). Patients with SP were excessively concerned about how they appear to others in social situations and indicated that they attempted to minimise manifestations of imperfection in this context. The two groups did not differ on other dimensions of PSPS. Non-display of imperfection has been implicated as a stronger predictor of psychopathology than nondisclosure of imperfection (Hewitt et al., 2003). Our findings indicate that self-presentation is an important interpersonal aspect of perfectionism and needs further study in SP. PSP also appears to be measuring core cognitive aspects, similar to the BFNE (Alden and Taylor, 2004). The absence of differences on other dimensions of PSPS (perfectionistic self-promotion and non-disclosure of imperfection) suggests that these are less likely to come under public scrutiny and are well within an individual’s control. However, these findings need further examination as PSPS has been largely studied in non-clinical student samples. A recent finding by Hewitt et al. (2008) indicates that as maladaptive interpersonal style, PSP is associated with significant anxiety. The sample size in our study was small and therefore limited the extent to which data could be analysed. While we controlled for influence of mood, we did not include a measure of neuroticism. Rosser et al., 2003 have indicated that both neuroticism and mood may influence the relationship between perfectionism and social anxiety. The inclusion of patients with Anxious Avoidant Personality Disorder (AAPD) and depressive disorders led to a
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certain heterogeneity of the sample. However, the sample was also typical of patients presenting with SP. Our sample was predominantly male and it is important to examine gender differences on these variables. We also did not examine subtypes of SP and there may be differences between patients specific and generalized SP. There is a paucity of published work from the Indian sub continent and few studies set in Asia on perfectionism. The present work is one of the few studies on perfectionism in SP in an Asian Indian sample. The study thus lends support to cross-cultural findings on perfectionism. The findings of this study will contribute to the understanding of second order personality factors, and their clinical implications. Future research must include larger samples and examine perfectionism across different psychiatric conditions as well as subtypes of SP. Cognitive behavioural interventions must also target beliefs regarding perfection and include measurement of perfectionism as an outcome variable. There is a need to examine the development of perfectionism from a longitudinal perspective. 5. Conclusions The present study highlights the importance of trait perfectionism in SP. Although several theoretical descriptions of perfectionism are available, there are few empirical studies on perfectionism in the context of anxiety disorders other than OCD. Perfectionism in the clinical setting hinders the progress of therapy, when clients set high standards for change, and are excessively self-critical. Psychological interventions addressing perfectionism are essential in order to reduce its negative impact. Funding None. Conflict of interests None. Acknowledgement The paper is based on the work carried out by the first author as part of an academic requirement, under the guidance of the second author. References Alden, L.E., Bieling, P., Wallace, S.T., 1994. Perfectionism in an interpersonal context: a self–regulation analysis of dysphoria and social anxiety. Cogn. Ther. Res. 18, 297–316. Alden, L.E., Taylor, C.T., 2004. Interpersonal processes in social phobia. Clin. Psychol. Rev. 24, 857–882. American Psychiatric Association, 1994. Diagnostic and Statistical Manual for Mental Disorders, 4th ed. American Psychiatric Association, Washington DC. Antony, M.M., Purdon, C.L., Huta, V., Swinson, R.P., 1998. Dimensions of perfectionism across the anxiety disorders. Behav. Res. Ther. 36, 1143–1154. Beck, A.T., Emery, G., Greenberg, R., 1985. Anxiety Disorders and Phobias: A Cognitive Perspective. Basic Books, New York. Beck, A.T., Steer, R.A., Brown, G.K., 1996. Manual for the Beck Depression InventoryII. Psychological Corporation, San Antonio, TX. Bruch, M.A., Heimberg, R.G., 1994. Differences in perceptions of parental and personal characteristics between generalized and nongeneralized social phobics. J. Anx. Disorder 8, 155–168. Bruce, S.E., Yonkers, K.A., Otto, M.W., Eisen, J.L., Weisberg, R.B., Pagano, M., Shea, M.T, Keller, M.B, 2005. Influence of psychiatric co morbidity on recovery and recurrence in generalized anxiety disorder, social phobia, and panic disorder: a 12-year prospective study. Am. J. Psychiatry 162, 1179–1187. Bruch, M.A., Heimberg, R.G., Berger, P., Collins, T.M., 1989. Social phobia and perception of early parental and personal characteristics. Anxiety Res. 2, 57–65. Chang, E.C., Sanna, L.J., 2001. Negative attributional style as a moderator of the link between perfectionism and depressive symptoms: preliminary evidence for an integrative model. J. Couns. Psychol. 48, 490–495.
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Dimensions of perfectionism and perfectionistic self-presentation in social phobia Mansi Jain, Paulomi M. Sudhir * Department of Mental Health and Social Psychology, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bangalore 560029, Karnataka, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 18 October 2009 Received in revised form 14 August 2010 Accepted 19 August 2010
In a cross sectional study we examined the dimensions of perfectionism and perfectionistic selfpresentation in patients with social phobia. We also examined associations between perfectionism and self-report of anxiety and depression with fear of negative evaluation. Thirty patients with a diagnosis of social phobia and 30 community volunteers completed two measures of trait perfectionism, fear of negative evaluation and measures of anxiety and depression. The clinical sample had overall higher levels of perfectionism and had greater fear of negative evaluation, social anxiety, trait anxiety and depression than the community sample. The clinical sample had significantly higher concern over mistakes, doubts over actions, parental criticism (F-MPS, Frost et al., 1990) and scored higher for nondisplay of imperfection on the Perfectionistic Self Presentation Scale (PSPS; Hewitt et al., 2003). The two groups did not differ on other dimensions of perfectionism, or on both measures of perfectionism. The two measures of perfectionism were positively correlated. There was a significant correlation between trait perfectionism and Brief Fear of Negative Evaluation scale (BFNE). The paper discusses the importance of examining perfectionism in social phobia. ß 2010 Elsevier B.V. All rights reserved.
Keywords: Perfectionism Social phobia Perfectionistic self-presentation Social anxiety
1. Introduction The hallmark of social phobia (SP) is a marked fear of social or performance situations, fear of scrutiny and negative evaluation and the avoidance of situations in which these fears are triggered (APA, 1994). It is the third most common psychiatric disorder (Kessler et al., 1994) with a poor rate of spontaneous remission (Bruce et al., 2005). The lifetime prevalence of SP ranges from 2.4% to 13%. Co-morbidity rates for SP are high and include other anxiety disorders, mood disorders, substance dependence and bulimia nervosa (Federoff and Taylor, 2001; Kessler et al., 1999). The onset of SP is typically early although people with SP seek treatment much later when they experience impairment in social and occupational roles. Persons with SP are excessively concerned with possible errors they may make in social situations and predict rejection or loss of status as a result of their behaviours. Fear of negative evaluation (FNE) is a core feature of SP and is associated with heightened negative affect and interpersonal awareness (Beck et al., 1985; Harb et al., 2002). It reflects the tendency to focus selectively on evidence of failure and to be self-critical. In order to avoid possible failure, persons with SP set unrealistically high standards for themselves (Clark and Wells, 1995; Rapee and Heimberg, 1997). These personally demanding standards are motivated largely by a
* Corresponding author. Tel.: +91 080 26995180; fax: +91 080 26564830. E-mail address: [email protected] (P.M. Sudhir). 1876-2018/$ – see front matter ß 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.ajp.2010.08.006
fear of failure and need to impress, which in turn leads to avoidance and hyper vigilance (Eysenck, 1997; Hamachek, 1978). Alden et al. (1994) suggest that persons with SP may actually set lower standards than their actual potential and may continually underestimate themselves. Clinical evidence suggests that perfectionism is relevant to SP (Heimberg, 1996; Juster et al., 1996). Perfectionism refers to the desire to achieve the highest standards of performance, in combination with unduly critical evaluations of one’s performance (Frost et al., 1990). It is a multidimensional personality trait, with both adaptive and maladaptive aspects (Hewitt and Flett, 1991). The first multidimensional measure of perfectionism was developed by Frost et al. (1990) and consists of six dimensions that include concern over mistakes, doubts about actions, parental expectations, personal standards, parental criticism, and organization. Perfectionism has been identified as a vulnerability factor in the development of depression (Chang and Sanna, 2001; Hewitt and Flett, 1991; Hewitt et al., 1996), and other psychological problems such as hopelessness, suicidality, (Hewitt et al., 1998; O’Connor and O’Connor, 2003), eating disorders (Minarik and Ahrens, 1996), obsessive–compulsive disorder and other anxiety disorders (Antony et al., 1998). Perfectionistic self-presentation (PSP) is yet another dimension of perfectionism that includes an interpersonal aspect (Hewitt et al., 2003). PSP includes an excessive need to appear perfect in the eyes of others, with distinct, stable dimensions of, perfectionistic self–promotion i.e., proactively promoting a perfect image, nondisclosure of imperfection i.e., concern over verbal disclosures of
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The MINI (the mini-international neuropsychiatric interview M.I.N.I; Sheehan et al., 1998) was used to confirm diagnosis of SP. The community sample was screened both on the General Health Questionnaire-12 (GHQ-12; Goldberg and Williams, 1988) and the MINI. The average age of participants in the two groups was 28.90 years (SD = 8.256), and 28.73 years (SD 7.334) in the clinical and community sample respectively. A majority of the participants in both groups were male (93% and 80%) and single (70% and 76.7%). Experts at the department of mental health and social psychology, NIMHANS reviewed the study for ethical considerations. A written informed consent was obtained from the participants. The order of administration was kept constant.
imperfection and non-display of imperfection i.e., concern over behavioural displays of imperfection (Hewitt et al., 2003). Although the two aspects of trait perfectionism overlap to a certain degree, they are considered to be conceptually distinct from each other and both function as vulnerabilities in the development of emotional problems (Dunkley et al., 2003). Research suggests that perfectionism is much more likely to develop in families where parental anxiety concerning social interactions is high and need for others’ approval is excessively emphasized (Bruch et al., 1989; Juster et al., 1996). Asian American samples report higher personal standards, strict parental control, lack of open communication with parents, and higher educational expectations and emotional alienation than their Caucasian peers (Kawamura et al., 2002). Patients with SP report a higher concern over mistakes, doubts of one’s action and parental criticism than community controls and patients with panic disorder (Juster et al., 1996; Saboonchi et al., 1999). However, this has been relatively less researched in comparison to other psychiatric conditions and there are no cross-cultural comparisons. The clinical implications of perfectionism and its role in maintenance of anxiety disorders and SP in particular, have received relatively less attention. High levels of clinical perfectionism that includes personally demanding standards with selfcriticality hampers the progress of therapy and maintains negative affect through excessive self-criticality (Shafran et al., 2002). Perfectionism and interpersonal aspects of perfectionism have been previously studied in western populations and largely in non-clinical samples and limit generalization of findings to other populations (Hewitt et al., 2003; Juster et al., 1996). In the Asian Indian setting, perfectionism has been explored in a few recent studies on university samples (Slaney et al., 2000). The cross-cultural aspects of perfectionism have been inadequately addressed in clinical samples. The need to examine cognitive features such as FNE in association with trait perfectionism has also been emphasized (Antony et al., 1998). The purpose of this study was to examine the dimensions of perfectionism patients with SP in an Asian Indian setting. We also examined associations between trait perfectionism and anxiety, depression, and FNE. Perfectionism, particularly its interpersonal aspects, is likely to be influenced by socio-cultural factors. To our knowledge there are no published studies examining trait perfectionism in a clinical sample in this cultural context. The findings of such a study would contribute to a cross-cultural understanding of perfectionism in SP.
Frost’s multidimensional perfectionism scale (F-MPS; Frost et al., 1990) is a 35 item questionnaire with six dimensions, namely concern over mistakes (CM), personal standards (PS), parental expectation (PE), parental criticism (PC), doubts about actions (DA) and organization (O). The reliability of the total perfectionism scale is 0.90. Internal consistency of the F-MPS ranges from 0.77 to 0.93. The perfectionistic self-presentation scale (PSPS; Hewitt et al., 2003) is a 27-item measure with three subscales: perfectionistic self-promotion, non-display of Imperfection and non-disclosure of Imperfection. Higher scores indicate greater levels of need for perfection. Coefficient alpha for PSPS subscales range from .75 to .90 (Hewitt et al., 2003). Brief fear of negative evaluation scale (BFNE; Leary, 1983) is a 12-item measure that assesses concerns over negative interpersonal evaluation, based upon the original FNE (Watson and Friend, 1969). It correlates highly (r = .96) with the original FNE and has demonstrated good test-retest reliability and internal consistency (Leary, 1983). Liebowitz social anxiety scale (LSAS; Liebowitz, 1987) measures fear and avoidance of social interactions and performance situations. LSAS has adequate psychometric properties. It was used as self-report of social anxiety in this study. State–trait anxiety inventory (STAI; Spielberger et al., 1983) is a 20 item self-report measure with two forms that assess state and trait anxiety. It is a widely used measure of anxiety with adequate psychometric properties. Beck depression inventory II: (BDI II, Beck et al., 1996) was used to assess severity of depression. Descriptive statistics, t-test, correlations and partial correlations were used to analyse the data obtained (Table 1).
2. Methods
3. Results
2.1. Sample and design
Sixty seven percent (67%) of the clinical sample had a primary diagnosis of SP, 33% had a diagnosis of SP with anxious avoidant personality disorder (AAPD). Research indicates that 60% of patients with SP also receive a diagnosis of AAPD (Heimberg, 1996). In addition, two patients had co-morbid depression that included recurrent depressive disorder and dysthymia. As expected the clinical sample scored higher than community controls (Table 2) on LSAS, (Mean = 72.53; t = 8.31, p < 001), state (Mean = 41.97; t = 3.29, p < .05) and trait anxiety (Mean = 54.60, t = 7.40, p < .001) indicating presence of significant anxiety symptoms at the time of assessment. The clinical sample had a mean BDI score of 17 (11.20), indicating mild severity of depressive symptoms. This was significantly higher than that of the community sample (t = 4.49, p < .001). The average duration of illness was 10.6 years (6.62), with a range of 3–28 years indicating a chronic course. Patients with SP had a significantly higher total score on F-MPS (Table 2; Mean = 92.4; t = 2.78, p < .001) than the community
Thirty patients with an ICD 10 (WHO, 1992) diagnosis of SP (F 40.1) and 30 community volunteers formed the sample for the study. A cross sectional, case control design was adopted. The clinical sample consisted of patients with a primary diagnosis of SP and was selected from the psychiatric outpatient services of NIMHANS, Bangalore. Patients with co-morbid anxious avoidant personality disorder (ICD 10; AAPD; F-60.0) and depressive disorders, other than severe depressive disorder, (F-32.2 and 32.3) were also included. The community sample was recruited using the snowball technique. Exclusion criteria were a diagnosis of psychosis, bipolar affective disorder, severe depressive episode with psychotic symptoms, other anxiety disorders, Axis II disorders other than anxious avoidant personality disorder, current psychoactive substance abuse, organic and neurological disorders and major physical illnesses or structured psychological intervention in the last 12 months for SP.
2.2. Measures
M. Jain, P.M. Sudhir / Asian Journal of Psychiatry 3 (2010) 216–221
218 Table 1 Socio-demographic description of the sample. Category
Clinical sample (n = 30)
Community control (n = 30)
28.90 8.256
28.73 7.334
Age Mean SD Category
Clinical sample (n = 30)
Community Control (n = 30)
n
%
n
%
Male Female
28 2
93.3% 6.7%
24 6
80.0% 20.0%
Graduate Post Graduate
17 7
56.7% 23.3%
7 17
23.3% 56.7%
Never married Married
21 9
70.0% 30.0%
23 7
76.7% 23.3%
Student Employed Unemployed
8 19
26.7% 63.3%
13 16
43.3% 53.3%
Hindu Others
24 6
80.0% 20.0%
25 5
83.3% 16.6%
Present Absent
10 20
33.3% 66.7%
8 22
26.7% 73.3%
Sex
Education
Marital status
Occupation
Religion
Family history
sample. When the two groups were compared on specific dimensions of perfectionism, the clinical sample had higher scores on CM (Mean = 28.8, SD = 7.2; t = 3.39, p < 0.001), PC (Mean = 12, SD = 3.1, t = 3.62, p < 0.001) and DA (Mean = 13.4, SD = 3.5, t = 4.14, p < 0.001). There were no differences on the other dimensions of the F-MPS. The community sample scored higher on PE although the difference was not statistically significant. Patients with SP reported greater FNE (Mean = 40.83; t = 6.07, p < .05). When we compared the two groups (Table 2) on the perfectionistic self-presentation scale (PSPS), the clinical group
reported a significantly higher need to appear perfect (Mean = 129.63; t = 2.84, p < .05) before others. The clinical group had a higher need for non–display of imperfection (Mean = 51.27; t = 3.74, p < 05). There were no differences between the two groups on PSP and non-disclosure of imperfection. Items on nondisplay of imperfection include, ‘‘Errors are much worse if they are made in public rather than in private’’ and ‘‘It would be awful if I made a fool of myself in front of others.’’ There was a significant positive association between FNE and PSPS (Table 3 r = .478, p < 01) and overall perfectionism on the F-MPS (Table 3; r = .398, p < .05) indicating that trait perfectionism is associated with cognitive aspects of SP. Perfectionism (F-MPS) and social anxiety were significantly correlated in the clinical sample (r = .440, p < .05). There was a modest association between PSPS and LSAS and state–trait anxiety (r = .332; p < .07 and 0.359; p < 0.05). Partial correlations controlling for the influence of mood using the BDI was carried out. The association between F-MPS and social anxiety continued to remain significant after controlling for depression (r = .415, p < .05) indicating a unique relationship between perfectionism and social anxiety. Total score on the F-MPS was significantly associated with LSAS, but not with STAI. There were no significant correlations between PSPS and the measures of anxiety and depression. PSPS was significantly associated with FNE, indicating that PSPS may be more specific to interpersonal aspects of perfectionism. CM was significantly associated with trait anxiety (r = .400; p < 0.05) and depression (r = .474; p < 0.01). DA was significantly associated with LSA-Fear, and depression (r = .432; p < 0.05). PS was significantly correlated with LSAS- Fear (r = .438; p < .0.05), but not with other measures of anxiety or depression. PC was significantly correlated with depression (r = .455; p < 0.05) but not with measures of anxiety. PE and organization did not correlate significantly with any of the measures of anxiety or depression. 4. Discussion In the present study we examined the dimensions of perfectionism and perfectionistic self-presentation in patients with SP and explored the association of trait perfectionism with FNE measures of anxiety and depression. Despite clinical evidence of perfectionism in patients with SP, there has been a paucity of
Table 2 Comparison of scores on measures of perfectionism (FMPS and PSPS) and brief fear of negative evaluation (BFNE), anxiety (LSAS and STAI) and depression (BDI). Measures
Clinical (n = 30) Mean
Frost’s multidimensional perfectionism scale Concern over mistakes Personal standards Parental expectations Parental criticism Doubt over Action Organization Total Perfectionistic self-presentation scale Perfectionistic self-promotion Non-display of imperfection Non-disclosure of imperfection Total Brief fear of negative evaluation Liebowitz social anxiety scale State–trait anxiety inventory – ST State–trait anxiety inventory – TR Beck’s depression inventory * **
p < .05. p < .01.
28.8 23.6 14.5 12 13.4 22.6 92.4
Control (n = 30) SD 7.2 6.9 4.2 3.1 3.5 4.3 19.2
Mean 22.1 22.3 16.2 9.4 9.9 23.2 79.9
t-values
Sig
SD 7.2 5.3 3.9 2.5 3.1 4.3 15.5
3.99** 0.842 1.6 3.62* 4.14** 0.507 2.78*
<0.001 0.404 0.119 0.001 <0.001 0.614 0.007
49.63 51.27 28.73 129.63
12.42 10.94 6.51 23.42
43.73 41.7 27.4 112.83
11.3 8.74 6.78 22.4
1.93 3.74** 0.777 2.84*
0.059 <0.001 0.44 0.006
40.83 72.53 41.97 54.60 17.10
8.00 20.88 9.00 8.26 11.20
29.67 29.40 34.17 38.20 6.53
6.14 19.28 9.37 8.89 6.37
6.07** 8.31** 3.29* 7.40** 4.49**
<0.001 <0.001 .002 <0.001 <0.001
M. Jain, P.M. Sudhir / Asian Journal of Psychiatry 3 (2010) 216–221
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Table 3 Correlations between measures of perfectionism (FMPS and PSPS) and brief fear of negative evaluation (BFNE), anxiety (LSAS and STAI). Measures
Brief fear of negative evaluation Leibowitz social anxiety scale STAI-state STAI- trait * **
Frost multidimensional perfectionism scale (FMPS)
Perfectionistic self-presentation scale (PSPS)
Clinical (n = 30)
Community (n = 30)
Clinical (n = 30)
r
Sig
r
Sig
r
Sig
Community (n = 30) r
Sig
.398* .440* 0.285 0.35
0.029 0.015 0.127 0.058
0.339 0.005 0.104 0.176
0.067 0.981 0.586 0.351
0.476** 0.332 0.197 0.359
0.008 0.073 0.297 0.051
0.185 0.081 0.131 0.007
0.328 0.669 0.492 0.973
p < .05. p < .01.
studies examining this area. The few studies that are available have been from western settings. Our sample was typical of patients seeking treatment for SP. A majority of the clinical sample comprised of young adults, males, belonging to an urban middle socioeconomic background, educated, with a chronic course and mild depressive symptoms. They reported depressive symptoms that were of mild severity but varied across the group. Higher rates of depression in SP arise possibly as a result of social isolation and low self-esteem (Stein et al., 1990). There were expected differences between the two groups on the overall scores of both measures of perfectionism and symptom measures. The clinical sample had higher concern over mistakes, doubts over one’s actions and parental criticism than the community sample. CM is a tendency towards critical self-evaluation, to equate mistakes with failure and expect negative responses from others (Frost et al., 1990; Rosser et al., 2003). Individuals with SP fail to appreciate their performance and experience self-doubt regarding their decisions (Juster et al., 1996). CM was significantly associated with both BFNE and non-display of imperfection, both of which measure excessive concern over failure and mistakes, as well as a need to conceal this. Rosser et al. (2003) suggest that there is an overlap between CM and FNE. The clinical sample endorsed a greater tendency to doubt the quality of one’s performance (Frost et al., 1990). This is manifested in the person’s attempt to make the right response in social interactions (Juster et al., 1996). DA is also reported to be high in patients with Obsessive Compulsive Disorder OCD (Antony et al., 1998) however, it is possible that concern in patients with SP is greater with regard to social interactions. Only certain dimensions of perfectionism were significantly correlated with anxiety and depression, indicating the need to examine and address these maladaptive dimensions more closely in future studies. The scores of the sample in our study were higher on all dimensions of F-MPS except personal standards, as compared to western samples (Juster et al., 1996). We used the ICD10 criteria in our study as this is currently in use in the setting of our study. Most studies reported have used the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria to identify SP. More studies are required to examine crosscultural variations in order to draw definitive conclusions across samples. The community sample reported higher PS. PS is considered to be an adaptive aspect of perfectionism, related to efficacy (Lundh, 2004; Stoeber et al., 2007). High levels of PS may become dysfunctional only when there is a large discrepancy between one’s standards and the perceived ability (Alden et al., 1994). The two groups did not differ on PE. PE is significantly associated with personal standards, a measure of self-expectations, (Frost et al., 1990) and parents of patients with SP rely more on the use of shame as a disciplinary technique indicative of greater criticism (Bruch et al., 1989; Bruch and Heimberg, 1994). Patients with SP reported greater PC while community participants reported greater PE, but not PC. These findings are
consistent with previous research on patients with SP (Juster et al., 1996). This further emphasizes the relevance of early learning patterns and experiences in the development of perfectionism. Perfectionism is hypothesized to develop more readily in families with overly critical and demanding parents (Bruch et al., 1989; Lieb et al., 2000). Our findings thus lend cross-cultural validity to the existing literature on perfectionism in SP. Studies carried out on Asian American participants indicate presence of greater harshness, criticism and concern over social behaviours and academic achievement in Asian American parents than in western counterparts. However, these findings are based on Asians living in western societies (Kawamura et al., 2002). Slaney et al. (2000) found that Asian Indian students who rated themselves higher on perfectionism had higher PS and order and reported great concerns over interpersonal relations. The key difference between Indian and American students was lower anxiety in Indian students. Dysfunctional cognitions in social anxiety are centered on social interactions, perceptions of self as seen by scrutiny by others (Clark and Wells, 1995). Previous researchers have examined public self-consciousness in SP but found it to be part of social anxiety and not perfectionism (Saboonchi et al., 1999). Self-presentation is described as a maladaptive interpersonal style and is identified as an aspect of perfectionism (Hewitt et al., 2003). Non-display of imperfection is the extreme concern over behaviourally demonstrating imperfection. It is usually expressed in avoidance of situations, where such shortcomings might be obvious and in efforts to conceal them (Hewitt et al., 2008; Higgins, 1998; Leary, 1993). Patients with SP were excessively concerned about how they appear to others in social situations and indicated that they attempted to minimise manifestations of imperfection in this context. The two groups did not differ on other dimensions of PSPS. Non-display of imperfection has been implicated as a stronger predictor of psychopathology than nondisclosure of imperfection (Hewitt et al., 2003). Our findings indicate that self-presentation is an important interpersonal aspect of perfectionism and needs further study in SP. PSP also appears to be measuring core cognitive aspects, similar to the BFNE (Alden and Taylor, 2004). The absence of differences on other dimensions of PSPS (perfectionistic self-promotion and non-disclosure of imperfection) suggests that these are less likely to come under public scrutiny and are well within an individual’s control. However, these findings need further examination as PSPS has been largely studied in non-clinical student samples. A recent finding by Hewitt et al. (2008) indicates that as maladaptive interpersonal style, PSP is associated with significant anxiety. The sample size in our study was small and therefore limited the extent to which data could be analysed. While we controlled for influence of mood, we did not include a measure of neuroticism. Rosser et al., 2003 have indicated that both neuroticism and mood may influence the relationship between perfectionism and social anxiety. The inclusion of patients with Anxious Avoidant Personality Disorder (AAPD) and depressive disorders led to a
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certain heterogeneity of the sample. However, the sample was also typical of patients presenting with SP. Our sample was predominantly male and it is important to examine gender differences on these variables. We also did not examine subtypes of SP and there may be differences between patients specific and generalized SP. There is a paucity of published work from the Indian sub continent and few studies set in Asia on perfectionism. The present work is one of the few studies on perfectionism in SP in an Asian Indian sample. The study thus lends support to cross-cultural findings on perfectionism. The findings of this study will contribute to the understanding of second order personality factors, and their clinical implications. Future research must include larger samples and examine perfectionism across different psychiatric conditions as well as subtypes of SP. Cognitive behavioural interventions must also target beliefs regarding perfection and include measurement of perfectionism as an outcome variable. There is a need to examine the development of perfectionism from a longitudinal perspective. 5. Conclusions The present study highlights the importance of trait perfectionism in SP. Although several theoretical descriptions of perfectionism are available, there are few empirical studies on perfectionism in the context of anxiety disorders other than OCD. Perfectionism in the clinical setting hinders the progress of therapy, when clients set high standards for change, and are excessively self-critical. Psychological interventions addressing perfectionism are essential in order to reduce its negative impact. Funding None. Conflict of interests None. Acknowledgement The paper is based on the work carried out by the first author as part of an academic requirement, under the guidance of the second author. References Alden, L.E., Bieling, P., Wallace, S.T., 1994. Perfectionism in an interpersonal context: a self–regulation analysis of dysphoria and social anxiety. Cogn. Ther. Res. 18, 297–316. Alden, L.E., Taylor, C.T., 2004. Interpersonal processes in social phobia. Clin. Psychol. Rev. 24, 857–882. American Psychiatric Association, 1994. Diagnostic and Statistical Manual for Mental Disorders, 4th ed. American Psychiatric Association, Washington DC. Antony, M.M., Purdon, C.L., Huta, V., Swinson, R.P., 1998. Dimensions of perfectionism across the anxiety disorders. Behav. Res. Ther. 36, 1143–1154. Beck, A.T., Emery, G., Greenberg, R., 1985. Anxiety Disorders and Phobias: A Cognitive Perspective. Basic Books, New York. Beck, A.T., Steer, R.A., Brown, G.K., 1996. Manual for the Beck Depression InventoryII. Psychological Corporation, San Antonio, TX. Bruch, M.A., Heimberg, R.G., 1994. Differences in perceptions of parental and personal characteristics between generalized and nongeneralized social phobics. J. Anx. Disorder 8, 155–168. Bruce, S.E., Yonkers, K.A., Otto, M.W., Eisen, J.L., Weisberg, R.B., Pagano, M., Shea, M.T, Keller, M.B, 2005. Influence of psychiatric co morbidity on recovery and recurrence in generalized anxiety disorder, social phobia, and panic disorder: a 12-year prospective study. Am. J. Psychiatry 162, 1179–1187. Bruch, M.A., Heimberg, R.G., Berger, P., Collins, T.M., 1989. Social phobia and perception of early parental and personal characteristics. Anxiety Res. 2, 57–65. Chang, E.C., Sanna, L.J., 2001. Negative attributional style as a moderator of the link between perfectionism and depressive symptoms: preliminary evidence for an integrative model. J. Couns. Psychol. 48, 490–495.
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