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Perfectionism and depression symptom severity in major depressive disorder
BEHAVIOUR RESEARCH AND THERAPY
PERGAMON
Behaviour Research and Therapy 37 (1999) 783±794
Perfectionism and depression symptom severity in major depressive disorder Murray W. Enns *, Brian J. Cox Department of Psychiatry, University of Manitoba, PZ-430 PsycHealth Centre, 771 Bannatyne Avenue, Winnipeg, Man., Canada R3E 3N4 Received 13 May 1998; accepted 6 October 1998
Abstract In recent years it has been recognized that perfectionism is a multidimensional construct and two Multidimensional Perfectionism Scales have been developed and investigated in relative isolation [Frost, R.O., Marten, P., Lahart, C., & Rosenblate, R. (1990). The dimensions of perfectionism. Cognitive Therapy and Research, 14, 449±468; Hewitt, P.L., & Flett, G.L. (1991). Perfectionism in the self and social contexts: Conceptualization, assessment and association with psychopathology. Journal of Personality and Social Psychology, 60, 456±470]. The present study sought to evaluate the association between various dimensions of perfectionism, higher-order personality dimensions, and self and observer rated depressive symptoms in a group of 145 patients with major depressive disorder. Only three of ten perfectionism dimensions (socially prescribed perfectionism, concern over mistakes and self-criticism) displayed medium to large correlations with depressive symptoms, especially self-report symptoms re¯ecting depressive cognitive distortions. The results are discussed in relation to the speci®city of perfectionism dimensions to depression, adaptive versus maladaptive aspects of perfectionism, and in the context of previous research, much of which has relied on college student samples. # 1999 Elsevier Science Ltd. All rights reserved. Keywords: Perfectionism; Self-criticism; Depression
1. Introduction Potentially maladaptive eects of perfectionism have been recognized for many years (Hollender, 1965; Hamachek, 1978). Perfectionism has been regarded as a predisposing factor for depression from both cognitive and psychoanalytic perspectives (Bibring, 1953; Beck, 1967). * Corresponding author. Tel.: +1-204-787-7078; fax: +1-204-787-4879; e-mail: [email protected] 0005-7967/99/$ - see front matter # 1999 Elsevier Science Ltd. All rights reserved. PII: S 0 0 0 5 - 7 9 6 7 ( 9 8 ) 0 0 1 8 8 - 0
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In recent years there has been considerable growth in the perfectionism literature, owing in part to the development of reliable and valid instruments to measure various aspects of perfectionism (for a review see Enns & Cox, in press). Working from dierent conceptual frameworks, two groups of investigators independently developed instruments entitled the `Multidimensional Perfectionism Scale' (MPS) (Frost et al., 1990; Hewitt & Flett, 1991a). The Frost et al. MPS has the following dimensions based largely on content and potential origins of perfectionism: (1) concern over mistakes, (2) personal standards, (3) parental expectations, (4) parental criticism, (5) doubts about actions and (6) organization. The Hewitt and Flett MPS has dimensions based on the direction of perfectionism: (1) self-oriented perfectionism, (2) other-oriented perfectionism and (3) socially prescribed perfectionism. Three studies of undergraduate students reported correlations between the Frost et al. MPS dimensions and self-reported depression (Frost et al., 1990; Frost et al., 1993; Minarik & Ahrens, 1996). In each report doubts about actions and concern over mistakes showed the strongest association with depression symptoms (concern over mistakes r = 0.28 to 0.52; doubts about actions r = 0.31 to 0.55). Personal standards and organization showed small or even negative correlations with depression (personal standards r = ÿ 0.32 to 0.21; organization r = ÿ 0.03 to 0.12). There are no published reports examining the relationship between the Frost et al. MPS dimensions and depression symptoms in clinically depressed samples. Several studies have reported correlations between the Hewitt and Flett MPS dimensions and depression symptoms in undergraduate student samples (Flett et al., 1995, 1991; Frost et al., 1993; Preusser et al., 1994; Saddler & Buckland, 1995; Saddler & Sacks, 1993). Socially prescribed perfectionism quite consistently showed the strongest correlation with depression (r = 0.22 to 0.52). Self-oriented perfectionism showed a more variable, though usually positive correlation with depression (r = ÿ 0.05 to 0.36), and other-oriented perfectionism generally showed a nonsigni®cant association with depression (r = ÿ 0.25 to 0.24). Hewitt and Flett (1991b) found that depressed patients had higher levels of self-oriented perfectionism than both anxiety patients and controls. Socially prescribed perfectionism was elevated in both depressed and anxiety subjects compared to controls. These results suggest that self-oriented perfectionism may be more speci®c to clinical depression. Finally, a prospective study of current and former depressed patients supported a speci®c vulnerability hypothesis (Hewitt, Flett, & Ediger, 1996). Self-oriented perfectionism interacted only with achievement stress to predict depressive symptoms. Socially prescribed perfectionism predicted depressive symptoms as a main eect, but did not show an interaction with stress in predicting depression. The studies reviewed above suggest that the dimensions of perfectionism described by Hewitt and Flett (1991a) and Frost et al. (1990) may vary considerably in their importance to depression. To date, socially prescribed perfectionism and self-oriented perfectionism have received the strongest support. However, there have been few studies on the relationship between the Frost et al. MPS dimensions and depression. Further, only one study has simultaneously investigated correlations between both the Hewitt & Flett and Frost MPS dimensions and self-report depression scores, and it relied on a college student sample (Frost et al., 1993). Socially prescribed perfectionism, concern over mistakes, and doubts about actions all showed signi®cant positive correlations with the Beck Depression Inventory (BDI: Beck,
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Steer, & Garbin, 1988) (socially prescribed perfectionism r = 0.23; concern over mistakes r = 0.28; doubts about actions r = 0.31). In a related vein, the relationship between depression and the lower-order personality factors dependency and self criticism (Blatt et al., 1976) or sociotropy and autonomy (Beck, 1983) has been extensively studied for over 15 years (Coyne & Whien, 1995). A signi®cant conceptual relationship between perfectionism and self-criticism has been noted (Blatt, 1995; Enns & Cox, 1997). For example, Blatt (1995) suggested that ``self-oriented perfectionism involves exceedingly high unrealistic standards and an intensive self-scrutiny and criticism'' (p. 1006). That is, self-criticism may be a maladaptive aspect of self-oriented perfectionism. Blatt also asserted that self-critical depressive individuals ``have a chronic fear of disapproval, criticism and rejection [and] strive for excessive achievement and perfection'' (p. 1009). This striving to achieve and maintain approval and acceptance by others is descriptively rather similar to socially prescribed perfectionism. Only one study directly comparing these alternative conceptualizations in relation to depression has been reported. Hewitt and Flett (1993) found that socially prescribed perfectionism and self-criticism both showed a strong cross sectional relationship with BDI score. Self-criticism also showed large correlations with both selforiented perfectionism (r = 0.57) and socially prescribed perfectionism (r = 0.50). The present investigation was conducted to examine the association between various dimensions of perfectionism and depression symptom severity in a group of patients with major depressive disorder. We sought to extend this area of research in several ways. First, the present report simultaneously assessed the association between depression symptoms and the dimensions of perfectionism described by Hewitt and Flett (1991a), and Frost et al. (1990), as well as the related dimension of self-criticism (Blatt et al., 1976). Second, since there has been general agreement that the 21 items of the BDI re¯ect 3 symptom factors (Beck et al., 1988; Steer et al., 1987), we evaluated the relationship between the dimensions of perfectionism and BDI `subscale' scores using the item assignments from the Steer et al. (1987) factor analytic study1. Third, we evaluated the relationship between perfectionism dimensions and both selfreported (BDI) and observer-rated (Hamilton Depression Rating Scale, HamD; Hamilton, 1960) depression symptoms. Fourth, because the higher-order personality variables of neuroticism and extraversion have been convincingly linked to depression (e.g., Clark & Watson, 1991; Enns & Cox, 1997), the present study also sought to determine whether these lower-order perfectionism variables would remain signi®cantly correlated with BDI scores when neuroticism and extraversion were statistically controlled. Based on previous research it was hypothesized that concern over mistakes, doubts about actions, socially prescribed perfectionism, and self-criticism would be most strongly associated with depression scores. It was also expected that the perfectionism dimensions would show a stronger association with the BDI `cognitive distortions' subscale compared to the `cognitive± aective' and `somatic complaints' subscales. Since the HamD is observer rated and strongly emphasizes somatic/vegetative depression symptoms, it was predicted that smaller correlations between the HamD and perfectionism would be observed. 1 A recent con®rmatory factor analytic study of 137 depressed outpatients from our program (Enns et al., 1998) found that BDI item scores showed a good ®t to the three-factor model of Steer et al. (1987).
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2. Method 2.1. Subjects The sample was comprised of 145 depressed outpatients (55 men, 90 women) who had been referred to the Mood Disorders Program of a university-aliated teaching hospital for a psychiatric assessment. The mean age of the patients was 43.6 years (S.D. = 12.5) with a range of 19 to 81 years. All participants gave written informed consent to use the information they provided for research purposes. The Structured Clinical Interview for DSM IV (SCID: First, Spitzer, Gibbon, & Williams, 1995) was used for diagnosis in the majority of cases (n = 79). The remainder of patients were clinically diagnosed by an experienced psychiatrist from the Mood Disorders Program using a semi-structured clinical interview. All of the subjects had a primary diagnosis of current Major Depressive Disorder and were nonpsychotic. A subset of the SCID-diagnosed group (n = 11) along with 9 subjects with other diagnoses (principally anxiety disorders) were interviewed and rated simultaneously by two raters. In 19 out of 20 cases there was agreement on the primary diagnosis. Inter-rater reliability data are not available for the non-SCID patients. 2.2. Measures The following self report instruments were completed by all subjects. 1. Multidimensional Perfectionism Scale (MPS; Hewitt & Flett, 1991a). This is a 45-item questionnaire that generates 3 subscale scores: Self-oriented perfectionism (which involves the setting of unrealistic standards and perfectionistic striving for the self), socially prescribed perfectionism (which involves the belief that signi®cant others expect oneself to be perfect) and other oriented perfectionism (setting unrealistic standards for others). 2. Multidimensional Perfectionism Scale (MPS: Frost et al., 1990). This is a 35-item questionnaire with 6 subscales: concern over mistakes (re¯ecting negative reactions to mistakes), personal standards (setting high standards for self evaluation), parental expectations (the belief that one's parents set very high goals), parental criticism (the perception that one's parents were overly critical), doubts about actions (the tendency to doubt one's abilities) and organization (the importance placed on orderliness). 3. NEO-Five Factor Inventory (NEO-FFI: Costa & McCrae, 1992). The NEO-FFI is a 60item personality inventory that yields scores for 5 higher-order personality factors: neuroticism, extraversion, openness-to-experience, agreeableness and conscientiousness. 4. Depressive Experiences Questionnaire (DEQ: Blatt et al., 1976). The DEQ is intended to assess two distinct characterological con®gurations associated with depression Ð dependent and self-critical. The present study utilized a reconstructed and validated 19-item version of the DEQ (Bagby et al., 1994a). 5. The Beck Depression Inventory (BDI) is a 21-item measure of depression symptoms. It has been demonstrated to be a valid and reliable measure of depression (Beck et al., 1988). Scores for the BDI cognitive aective subscale were calculated as the sum of items 1, 2, 4, 9, 11, 12, 13, 15, 17 and 21; scores for the BDI cognitive distortions subscale were calculated
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Table 1 Correlations between Perfectionism dimensions and Depression Symptoms, Neuroticism and Extraversion BDI
Hewitt and Flett MPS Socially prescribed Self-oriented Other oriented
BDI cognitive distortions
BDI somatic complaints
HamD-17 Neuroticism Extraversion
0.33** 0.16 0.17*
0.55** 0.23** 0.25**
0.07 ÿ0.04 ÿ0.04
0.23* 0.19 0.26*
0.34** 0.17* 0.15
ÿ0.24** ÿ0.11 ÿ0.17*
Frost MPS Concern over mistakes 0.51** 0.40** ** Doubts about actions 0.31 0.28** * Parental criticism 0.21 0.09 Parental expectations 0.17* 0.12 Personal standards 0.05 0.05 Organization ÿ0.14 ÿ0.19*
0.57** 0.35** 0.32** 0.21* 0.10 ÿ0.06
0.08 ÿ0.02 0.01 0.02 ÿ0.15 ÿ0.06
0.28* 0.15 ÿ0.05 0.08 0.09 0.05
0.55** 0.56** 0.29** 0.13 0.03 ÿ0.23**
ÿ0.28** ÿ0.35** 0.00 0.05 0.12 0.21*
0.59**
0.07
0.66**
ÿ0.37**
DEQ Self-criticism
0.45** 0.19* 0.20*
BDI cognitive aective
0.55**
0.47**
n = 145 except for HamD-17 where n = 79.*p < 0.05,
**
0.32**
p < 0.01.
as the sum of items 3, 5, 6, 7, 8 and 14; scores for the BDI somatic complaints subscale were calculated as the sum of items 16, 18, 19 and 20 (based on Steer et al., 1987). 6. In addition to the self report measures, Hamilton Depression Ratings (HamD-17: Hamilton, 1960) were performed on a subset of 79 subjects using the Structured Interview Guide for the Hamilton Rating Scale (Williams, 1988).
3. Results The mean BDI score in the group was 30.0 (S.D. = 9.5) with a range of 112 to 52. The mean HamD-17 score was 22.1 (S.D. = 3.8) with a range of 10 to 30. Table 1 shows the correlations between the dierent perfectionism dimensions and BDI scores, BDI subscale scores, HamD-17 ratings and higher-order personality factors theoretically related to depression (neuroticism, extraversion). The eect size criteria speci®ed by Cohen (1992) can be used to describe the degree of correlation (medium rr 0.3, large r r0.5). In general, socially prescribed perfectionism, concern over mistakes, doubts about actions, and self-criticism, had 2
A BDI score of 11 is unusual for a patient with major depression; a review of this subject's record indicated that he was suering from a mild but de®nite MDE, and that the symptoms endorsed on his BDI corresponded to the symptoms found in a clinical interview. Thus, the BDI was considered to have been validly completed.
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medium to large correlations with BDI scores, particularly with the BDI cognitive distortions factor, had signi®cant though smaller correlations with HamD scores, were positively correlated with neuroticism, and were negatively correlated with extraversion. Speci®c hypotheses regarding the relative magnitudes of correlation coecients were tested using the method of Meng et al. (1992). We predicted that the perfectionism dimensions would show a stronger association with the BDI cognitive distortions subscale compared to the cognitive±aective and somatic complaints subscales. Numerically, the correlations between the perfectionism dimensions and BDI cognitive distortions were higher than those with BDI cognitive±aective in every instance. These dierences reached signi®cance for socially prescribed perfectionism (Z = 3.64, p < 0.001), concern over mistakes (Z = 2.91, p < 0.01), parental criticism (Z = 3.43, p < 0.001), and self criticism (Z = 2.13, p < 0.05). The correlations between the perfectionism dimensions and BDI cognitive distortions were substantially higher than those with BDI somatic complaints. These dierences reached signi®cance for socially prescribed perfectionism (Z = 4.93, p < 0.0001), self oriented perfectionism (Z = 2.56, p < 0.01), other oriented perfectionism (Z = 2.75, p < 0.01), concern over mistakes (Z = 5.10, p < 0.0001), doubts about actions (Z = 3.56, p < 0.001), parental criticism (Z = 2.99, p < 0.01) and self criticism (Z = 5.44, p < 0.0001). (The personal standards and organization subscales were not subjected to these comparisons as no pattern of signi®cant relationships with any of the depression scales was observed.) We also predicted that the correlations between perfectionism dimensions and HamD scores would be smaller than the corresponding correlations with BDI scores. Analyses for this hypothesis were limited to the 79 subjects for whom we had both BDI and HamD scores. Numerically, most (but not all) of the perfectionism dimensions were more strongly correlated with BDI scores. These dierences were signi®cant for socially prescribed perfectionism (Z = 2.42, p < 0.01), concern over mistakes (Z = 2.62, p < 0.01), parental criticism (Z = 3.01, p < 0.01), parental expectations (Z = 1.82, p < 0.05) and self criticism (Z = 2.71, p < 0.01). Table 2 shows the partial correlations between the perfectionism dimensions and depression scores, after controlling for neuroticism and extraversion. Although somewhat reduced, three of the four perfectionism variables continued to be correlated with BDI scores and the BDI cognitive distortions subscale in particular: socially prescribed perfectionism, concern over mistakes, and self-criticism3. To help clarify whether the above ®ndings re¯ect dierences between the perfectionism constructs (as opposed to dierences between the measures of the constructs), disattenuated correlations (rd) were computed [rd=r/Z(rxx.ryy), where r is the correlation coecient, rxx and 3
A series of hierarchical regression analyses were performed where dependent variables included BDI score, the BDI subscales, and HamD score. Neuroticism and extraversion scores were force-entered in the ®rst block and the three perfectionism dimensions with medium or large correlations with the dependent variable were force-entered in the second block. In each case, one or two of the same three perfectionism dimensions (socially prescribed perfectionism, concern over mistakes, and self-criticism) were signi®cant predictors in the regression equation and the others were not, but the same predictor variable(s) was not consistently identi®ed. We therefore chose not to present these results because they appeared to convey a misleading impression of speci®city in the relationship between perfectionism dimensions and the dierent depression measures.
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Table 2 Partial correlations between Perfectionism dimensions and Depression symptoms (Neuroticism and Extraversion partialled out) BDI
BDI cognitive aective
BDI cognitive distortions
BDI somatic complaints
HamD-17
Hewitt and Flett MPS Socially prescribed Self-oriented Other oriented
0.32** 0.08 0.10
0.16 0.06 0.07
0.45** 0.15 0.17*
0.04 ÿ0.08 ÿ0.08
0.18 0.17 0.24*
Frost MPS Concern over mistakes Doubts about actions Parental criticism Parental expectations Personal standards Organization
0.29** ÿ0.06 0.16 0.21* 0.06 0.02
0.15 ÿ0.07 0.00 0.13 0.07 ÿ0.05
0.38** 0.03 0.27** 0.23** 0.12 0.11
0.06 ÿ0.09 0.06 0.07 ÿ0.14 ÿ0.03
0.26* 0.09 ÿ0.08 0.09 0.11 0.12
0.34**
0.03
DEQ Self-criticism
0.27**
0.17*
n = 145 except for HamD-17 where n = 79.*p < 0.05,
**
0.32**
p < 0.01.
ryy are reliability coecients]. These results are presented in Table 3. As can be seen, the overall pattern of results does not dier substantially from that presented in Table 1. The distributions of all scale scores were evaluated for the presence of skew. Two of the distributions were signi®cantly negatively skewed (organization and neuroticism). Log transformations of these scale scores corrected the skew. The analyses presented in Tables 1 and 2 were then repeated with the log transformed data. Although there were minor changes in the magnitude of correlations and partial correlations involving these two variables, there was no substantial change in the observed pattern of results. The distributions of all scale scores were also evaluated for the presence of outliers. No signi®cant outliers were detected. Antidepressant medications were being taken by just over half of our study participants (74/ 145). Hypothetically the use of such treatments may have had a preferential eect in the treatment of certain kinds of depressive symptoms (e.g. neurovegetative symptoms). Therefore a comparison of antidepressant users/non users was conducted. No signi®cant dierences between groups was observed with regard to age, gender, depression scores or any of the perfectionism scale scores. Furthermore the pattern and magnitude of correlations between perfectionism dimensions and depression scores was essentially the same in the two groups. The relationships among the dierent perfectionism dimensions used in the study are shown in Table 4. As can be seen, the organization subscale of the Frost MPS shows the weakest correlations with other perfectionism subscales. Self-criticism showed large correlations with each of socially prescribed perfectionism, concern over mistakes and doubts about actions.
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Table 3 Disattenuated correlations (rd) between Perfectionism dimensions, Depression symptoms, N and E BDI
Hewitt and Flett MPS Socially prescribed Self-oriented Other oriented
BDI cognitive aective
BDI cognitive distortions
BDI somatic complaints
HamD-17 Neuroticism Extraversion
0.52 0.22 0.24
0.39 0.19 0.21
0.67 0.28 0.32
0.11 ÿ0.06 ÿ0.07
0.28 0.23 0.33
0.40 0.20 0.18
ÿ0.28 ÿ0.13 ÿ0.21
Frost MPS Concern over mistakes 0.59 Doubts about actions 0.38 Parental criticism 0.26 Parental expectations 0.20 Personal standards 0.06 Organization ÿ0.16
0.48 0.35 0.11 0.14 0.06 ÿ0.22
0.69 0.45 0.42 0.26 0.13 ÿ0.07
0.13 0.04 0.02 0.03 ÿ0.26 ÿ0.10
0.34 0.19 ÿ0.06 0.10 0.12 0.06
0.64 0.70 0.36 0.15 0.04 ÿ0.26
ÿ0.33 ÿ0.44 0.00 0.06 0.15 0.25
0.60
0.77
0.12
0.42
0.83
ÿ0.47
DEQ Self-criticism
0.68
n = 145 except for HamD-17 column n = 79.rd=r/Z(rxx.ryy), where r is the correlation coecient, rxx and ryy are reliability coecients.
Table 4 Correlations among perfectionism dimensions (1) Hewitt and Flett MPS (1) Socially prescribed (2) Self oriented (3) Other oriented Frost MPS (4) Concern over mistakes (5) Doubts about actions (6) Parental criticism (7) Parental expectations (8) Personal standards (9) Organization DEQ (10) Self-criticism N = 145, *p < 0.05,
**
(2)
(3)
± 0.61** 0.55**
± 0.58**
±
0.70** 0.46** 0.49** 0.49** 0.38** ÿ0.02
0.52** 0.43** 0.33** 0.46** 0.66** 0.27**
0.50**
0.29**
p < 0.01.
(4)
(5)
(6)
(7)
(8)
0.41** 0.32** 0.18* 0.26** 0.40** 0.15
± 0.55** 0.44** 0.46** 0.46** ÿ0.03
± 0.22** 0.16 0.24** ÿ0.10
± 0.62** 0.33** 0.12
± 0.50** 0.23**
± 0.28**
0.27**
0.61**
0.50**
0.25**
0.11
0.16
(9)
±
ÿ0.05
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4. Discussion The results of this investigation generally supported the study hypotheses. Three of the ten perfectionism dimensions examined consistently displayed correlations re¯ecting medium to large eect sizes with self-report depression symptoms. These were socially prescribed perfectionism, concern over mistakes and self criticism. Importantly, medium-sized correlations remained when the eects of neuroticism and extraversion were partialled out. As expected, the magnitude of correlations between (self-reported) perfectionism scores and observer-rated depression symptoms was less than that observed between perfectionism scores and self-reported depression symptoms. These dierences may simply be attributable to the reporting method (i.e. self vs. observer ratings). Our data also suggest an alternative explanation. The HamD scale strongly emphasizes somatic/vegetative symptoms in rating depression, and the somatic complaints factor of the BDI did not show a substantial relationship with any of the perfectionism dimensions. Thus, a weak relationship between perfectionism and the somatic manifestations of depression may explain the observed pattern of results. The BDI cognitive distortions subscale repeatedly showed larger correlations with perfectionism dimensions than did the BDI cognitive aective and somatic complaints subscales. This is consistent with the observation that perfectionistic beliefs commonly underlie distorted automatic thoughts in depression (e.g., Burns, 1980). Future research might determine whether persons scoring high in these perfectionistic dimensions also experience a qualitatively distinct form of depression, perhaps characterized by self-blame and guilt (i.e., pathoplastic eects of perfectionism on the depressive experience). Perhaps the most noteworthy observation in the present study is the great variability in the magnitude (and direction) of correlations between the perfectionism dimensions and depression symptoms. After controlling for the eects of higher-order personality variables related to depression (Clark & Watson, 1991), three speci®c forms of perfectionism showed moderate to large correlations with depression symptoms. In sharp contrast, personal standards and organization showed very small or inverse relationships with depression symptoms. These ®ndings might be re¯ective of a proposed distinction between positive/adaptive and negative/ maladaptive perfectionism that has been suggested by a number of authors (Frost et al., 1993; Slaney et al., 1995; Terry-Short et al., 1995). In studies of college students, both Frost et al. (1993) and Slaney et al. (1995) reported conceptually unambiguous 2 factor solutions of the Frost et al. (1990) and Hewitt and Flett (1991a) perfectionism subscales into positive achievement striving and maladaptive evaluation concerns. The positive factor in both studies included self-oriented perfectionism, other oriented perfectionism, personal standards and organization; each of these scales showed small to negative correlations with depression symptoms and neuroticism in the present study. The negative factor identi®ed by Frost et al. (1993) and Slaney et al. (1995) included socially prescribed perfectionism, concern over mistakes, doubts about actions, parental criticism and parental expectations; the ®rst three of these subscales showed at least medium sized (rr 0.3) correlations with BDI scores and neuroticism in the present study. Future work in the area of assessment might involve a more explicit distinction between adaptive and maladaptive dimensions of perfectionism, with the goal of more accurately identifying vulnerability to psychopathology.
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On the basis of such ®ndings, it is clear that distinguishing multiple dimensions of perfectionism is important in understanding the relationship between perfectionism and depressive symptoms. In comparison to the Hewitt and Flett MPS, little research on the relationship between the Frost et al. MPS and depression has been reported (apart from correlational studies in college students). The present results suggest at least two of the Frost et al. MPS dimensions (concern over mistakes and doubts about actions) appear as likely candidates for depression vulnerability factors. Further investigations of perfectionism and depression using the Frost et al. MPS are clearly warranted. Previous studies of self-criticism and depression have consistently identi®ed strong cross sectional correlations with depression symptoms (Blatt et al., 1982; Brown & Silberschatz, 1989; Nietzel & Harris, 1990). Longitudinal studies have also provided evidence that self criticism predisposes to the development of depression, and interacts with matched stresses (achievement related events) to predict depression (Hammen et al., 1985; Segal et al., 1992). In the present study self-criticism showed the numerically highest bivariate correlation with BDI scores of all the perfectionism variables. Thus, both the conceptual relationship between selfcriticism and other perfectionism dimensions (Blatt, 1995; Enns & Cox, 1997), and the similar magnitude of correlations with self and observer rated depression symptoms support the need for further studies comparing these alternative formulations. Though a cross-sectional correlation with depression symptoms may identify a personality trait as a potential vulnerability factor for depression (e.g., Nietzel & Harris, 1990), it has also been argued that a vulnerability factor for depression needs to be carefully distinguished from current manifestations of depression (e.g., Blaney & Kutcher, 1991). We were unable to identify any studies assessing the eect of the depressed state on the measurement of perfectionism, but several reports have indicated that self-criticism is state dependent (Klein et al., 1988; Franche & Dobson, 1992; Bagby et al., 1994b). This represents an important area for future study. Interestingly, in the present (and other) studies self-oriented perfectionism showed a relatively modest correlation with depression symptoms. Yet, a four-month longitudinal study of former depressed patients found that self-oriented perfectionism interacted with achievement stresses to predict time 2 depression (Hewitt et al., 1996). Thus, some perfectionism variables may only show a relationship with depression under conditions of matching stress. Coyne and Whien (1995) have emphasized another reason to assess stressors (social context) in studying the relationship between personality and depression. Personality measures are, of course, intended to tap an enduring trait, however, such measures may also re¯ect the eects of particular stresses in the individual's social context (e.g. a person who recently was ®red due to poor work performance may be expected to endorse a high level of concern over mistakes). In summary, the present study demonstrated that three perfectionism dimensions from three dierent psychometric measures are signi®cantly associated with both self and observer rated depression symptoms in patients with major depressive disorder. Previous prospective studies have provided some support for self-oriented perfectionism, socially prescribed perfectionism and self-criticism as vulnerability factors for depression. However, several of the Frost et al. (1990) perfectionism dimensions appear to be candidates worthy of further study as well. Further longitudinal studies of speci®c vulnerabilities to depression might bene®t from
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including a more comprehensive assessment of perfectionism with a variety of measures to compare competing conceptualizations of the perfectionism construct.
Acknowledgements Results of this research were presented at the annual conventions of the Association for Advancement of Behavior Therapy, New York City, November 1996, and the Canadian Psychiatric Association, September 1997.
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Frost, R. O., Heimberg, R. G., Holt, C. S., Mattia, J. I., & Neubauer, A. L. (1993). A comparison of two measures of perfectionism. Personality and Individual Dierences, 14, 119±126. Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R. (1990). The dimensions of perfectionism. Cognitive Therapy and Research, 14, 449±468. Hamachek, D. E. (1978). Psychodynamics of normal and neurotic perfectionism. Psychology, 15, 27±33. Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry, 23, 56±62. Hammen, C., Marks, T., Mayol, A., & de Mayo, R. (1985). Depressive self-schemes, life stress and vulnerability to depression. Journal of Abnormal Psychology, 94, 308±319. Hewitt, P. L., & Flett, G. L. (1991a). Perfectionism in the self and social contexts: Conceptualization, assessment and association with psychopathology. Journal of Personality and Social Psychology, 60, 456±470. Hewitt, P. L., & Flett, G. L. (1991b). Dimensions of perfectionism in unipolar depression. Journal of Abnormal Psychology, 100, 98± 101. Hewitt, P. L., & Flett, G. L. (1993). Dimensions of perfectionism, daily stress and depression: A test of the speci®c vulnerability hypothesis. Journal of Abnormal Psychology, 102, 58±65. Hewitt, P. L., Flett, G. L., & Ediger, E. (1996). Perfectionism and depression: longitudinal assessment of a speci®c vulnerability hypothesis. Journal of Abnormal Psychology, 105, 276±280. Hollender, M. H. (1965). Perfectionism. Comprehensive Psychiatry, 6, 94±103. Klein, D. N., Harding, K., Taylor, E. B., & Dickstein, S. (1988). Dependency and self-criticism in depression: evaluation in a clinical population. Journal of Abnormal Psychology, 97, 399±404. Meng, X. L., Rosenthal, R., & Rubin, D. B. (1992). Comparing correlated correlation coecients. Psychological Bulletin, 111, 172± 175. Minarik, M. L., & Ahrens, A. H. (1996). Relations of eating behaviour and symptoms of depression and anxiety to the dimensions of perfectionism among undergraduate women. Cognitive Therapy and Research, 20, 155±169. Nietzel, M. T., & Harris, M. J. (1990). Relationship of dependency and achievement/autonomy to depression. Clinical Psychology Review, 20, 279±297. Preusser, K. J., Rice, K. G., & Ashby, J. S. (1994). The role of self-esteem in mediating the perfectionism Ð depression connection. Journal of College Student Development, 35, 88±93. Saddler, C. D., & Buckland, R. L. (1995). The Multidimensional Perfectionism Scale: correlations with depression in college students with learning disabilities. Psychological Reports, 77, 483±490. Saddler, C. D., & Sacks, L. A. (1993). Multidimensional perfectionism and academic procrastination: relationships with depression in university students. Psychological Reports, 73, 863±871. Segal, Z. V., Shaw, B. F., Vella, D. D., & Katz, R. (1992). Cognitive and life stress predictors of relapse in remitted unipolar depressed patients: test of the congruency hypothesis. Journal of Abnormal Psychology, 101, 26±36. Slaney, R. B., Ashby, J. S., & Trippi, J. (1995). Perfectionism: its measurement and career relevance. Journal of Career Assessment, 3, 279±297. Steer, R. A., Beck, A. T., Riskind, J. H., & Brown, G. (1987). Relationship between the Beck Depression Inventory and the Hamilton Psychiatric Rating Scale for Depression in depressed outpatients. Journal of Psychopathology and Behavioral Assessment, 9, 327±339. Terry-Short, L. A., Owens, R. G., Slade, P. D., & Dewey, M. E. (1995). Positive and negative perfectionism. Personality and Individual Dierences, 18, 663±668. Williams, J. B. (1988). A structured interview guide for the Hamilton Depression Rating Scale. Archives of General Psychiatry, 45, 742± 747.
PERGAMON
Behaviour Research and Therapy 37 (1999) 783±794
Perfectionism and depression symptom severity in major depressive disorder Murray W. Enns *, Brian J. Cox Department of Psychiatry, University of Manitoba, PZ-430 PsycHealth Centre, 771 Bannatyne Avenue, Winnipeg, Man., Canada R3E 3N4 Received 13 May 1998; accepted 6 October 1998
Abstract In recent years it has been recognized that perfectionism is a multidimensional construct and two Multidimensional Perfectionism Scales have been developed and investigated in relative isolation [Frost, R.O., Marten, P., Lahart, C., & Rosenblate, R. (1990). The dimensions of perfectionism. Cognitive Therapy and Research, 14, 449±468; Hewitt, P.L., & Flett, G.L. (1991). Perfectionism in the self and social contexts: Conceptualization, assessment and association with psychopathology. Journal of Personality and Social Psychology, 60, 456±470]. The present study sought to evaluate the association between various dimensions of perfectionism, higher-order personality dimensions, and self and observer rated depressive symptoms in a group of 145 patients with major depressive disorder. Only three of ten perfectionism dimensions (socially prescribed perfectionism, concern over mistakes and self-criticism) displayed medium to large correlations with depressive symptoms, especially self-report symptoms re¯ecting depressive cognitive distortions. The results are discussed in relation to the speci®city of perfectionism dimensions to depression, adaptive versus maladaptive aspects of perfectionism, and in the context of previous research, much of which has relied on college student samples. # 1999 Elsevier Science Ltd. All rights reserved. Keywords: Perfectionism; Self-criticism; Depression
1. Introduction Potentially maladaptive eects of perfectionism have been recognized for many years (Hollender, 1965; Hamachek, 1978). Perfectionism has been regarded as a predisposing factor for depression from both cognitive and psychoanalytic perspectives (Bibring, 1953; Beck, 1967). * Corresponding author. Tel.: +1-204-787-7078; fax: +1-204-787-4879; e-mail: [email protected] 0005-7967/99/$ - see front matter # 1999 Elsevier Science Ltd. All rights reserved. PII: S 0 0 0 5 - 7 9 6 7 ( 9 8 ) 0 0 1 8 8 - 0
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In recent years there has been considerable growth in the perfectionism literature, owing in part to the development of reliable and valid instruments to measure various aspects of perfectionism (for a review see Enns & Cox, in press). Working from dierent conceptual frameworks, two groups of investigators independently developed instruments entitled the `Multidimensional Perfectionism Scale' (MPS) (Frost et al., 1990; Hewitt & Flett, 1991a). The Frost et al. MPS has the following dimensions based largely on content and potential origins of perfectionism: (1) concern over mistakes, (2) personal standards, (3) parental expectations, (4) parental criticism, (5) doubts about actions and (6) organization. The Hewitt and Flett MPS has dimensions based on the direction of perfectionism: (1) self-oriented perfectionism, (2) other-oriented perfectionism and (3) socially prescribed perfectionism. Three studies of undergraduate students reported correlations between the Frost et al. MPS dimensions and self-reported depression (Frost et al., 1990; Frost et al., 1993; Minarik & Ahrens, 1996). In each report doubts about actions and concern over mistakes showed the strongest association with depression symptoms (concern over mistakes r = 0.28 to 0.52; doubts about actions r = 0.31 to 0.55). Personal standards and organization showed small or even negative correlations with depression (personal standards r = ÿ 0.32 to 0.21; organization r = ÿ 0.03 to 0.12). There are no published reports examining the relationship between the Frost et al. MPS dimensions and depression symptoms in clinically depressed samples. Several studies have reported correlations between the Hewitt and Flett MPS dimensions and depression symptoms in undergraduate student samples (Flett et al., 1995, 1991; Frost et al., 1993; Preusser et al., 1994; Saddler & Buckland, 1995; Saddler & Sacks, 1993). Socially prescribed perfectionism quite consistently showed the strongest correlation with depression (r = 0.22 to 0.52). Self-oriented perfectionism showed a more variable, though usually positive correlation with depression (r = ÿ 0.05 to 0.36), and other-oriented perfectionism generally showed a nonsigni®cant association with depression (r = ÿ 0.25 to 0.24). Hewitt and Flett (1991b) found that depressed patients had higher levels of self-oriented perfectionism than both anxiety patients and controls. Socially prescribed perfectionism was elevated in both depressed and anxiety subjects compared to controls. These results suggest that self-oriented perfectionism may be more speci®c to clinical depression. Finally, a prospective study of current and former depressed patients supported a speci®c vulnerability hypothesis (Hewitt, Flett, & Ediger, 1996). Self-oriented perfectionism interacted only with achievement stress to predict depressive symptoms. Socially prescribed perfectionism predicted depressive symptoms as a main eect, but did not show an interaction with stress in predicting depression. The studies reviewed above suggest that the dimensions of perfectionism described by Hewitt and Flett (1991a) and Frost et al. (1990) may vary considerably in their importance to depression. To date, socially prescribed perfectionism and self-oriented perfectionism have received the strongest support. However, there have been few studies on the relationship between the Frost et al. MPS dimensions and depression. Further, only one study has simultaneously investigated correlations between both the Hewitt & Flett and Frost MPS dimensions and self-report depression scores, and it relied on a college student sample (Frost et al., 1993). Socially prescribed perfectionism, concern over mistakes, and doubts about actions all showed signi®cant positive correlations with the Beck Depression Inventory (BDI: Beck,
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785
Steer, & Garbin, 1988) (socially prescribed perfectionism r = 0.23; concern over mistakes r = 0.28; doubts about actions r = 0.31). In a related vein, the relationship between depression and the lower-order personality factors dependency and self criticism (Blatt et al., 1976) or sociotropy and autonomy (Beck, 1983) has been extensively studied for over 15 years (Coyne & Whien, 1995). A signi®cant conceptual relationship between perfectionism and self-criticism has been noted (Blatt, 1995; Enns & Cox, 1997). For example, Blatt (1995) suggested that ``self-oriented perfectionism involves exceedingly high unrealistic standards and an intensive self-scrutiny and criticism'' (p. 1006). That is, self-criticism may be a maladaptive aspect of self-oriented perfectionism. Blatt also asserted that self-critical depressive individuals ``have a chronic fear of disapproval, criticism and rejection [and] strive for excessive achievement and perfection'' (p. 1009). This striving to achieve and maintain approval and acceptance by others is descriptively rather similar to socially prescribed perfectionism. Only one study directly comparing these alternative conceptualizations in relation to depression has been reported. Hewitt and Flett (1993) found that socially prescribed perfectionism and self-criticism both showed a strong cross sectional relationship with BDI score. Self-criticism also showed large correlations with both selforiented perfectionism (r = 0.57) and socially prescribed perfectionism (r = 0.50). The present investigation was conducted to examine the association between various dimensions of perfectionism and depression symptom severity in a group of patients with major depressive disorder. We sought to extend this area of research in several ways. First, the present report simultaneously assessed the association between depression symptoms and the dimensions of perfectionism described by Hewitt and Flett (1991a), and Frost et al. (1990), as well as the related dimension of self-criticism (Blatt et al., 1976). Second, since there has been general agreement that the 21 items of the BDI re¯ect 3 symptom factors (Beck et al., 1988; Steer et al., 1987), we evaluated the relationship between the dimensions of perfectionism and BDI `subscale' scores using the item assignments from the Steer et al. (1987) factor analytic study1. Third, we evaluated the relationship between perfectionism dimensions and both selfreported (BDI) and observer-rated (Hamilton Depression Rating Scale, HamD; Hamilton, 1960) depression symptoms. Fourth, because the higher-order personality variables of neuroticism and extraversion have been convincingly linked to depression (e.g., Clark & Watson, 1991; Enns & Cox, 1997), the present study also sought to determine whether these lower-order perfectionism variables would remain signi®cantly correlated with BDI scores when neuroticism and extraversion were statistically controlled. Based on previous research it was hypothesized that concern over mistakes, doubts about actions, socially prescribed perfectionism, and self-criticism would be most strongly associated with depression scores. It was also expected that the perfectionism dimensions would show a stronger association with the BDI `cognitive distortions' subscale compared to the `cognitive± aective' and `somatic complaints' subscales. Since the HamD is observer rated and strongly emphasizes somatic/vegetative depression symptoms, it was predicted that smaller correlations between the HamD and perfectionism would be observed. 1 A recent con®rmatory factor analytic study of 137 depressed outpatients from our program (Enns et al., 1998) found that BDI item scores showed a good ®t to the three-factor model of Steer et al. (1987).
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2. Method 2.1. Subjects The sample was comprised of 145 depressed outpatients (55 men, 90 women) who had been referred to the Mood Disorders Program of a university-aliated teaching hospital for a psychiatric assessment. The mean age of the patients was 43.6 years (S.D. = 12.5) with a range of 19 to 81 years. All participants gave written informed consent to use the information they provided for research purposes. The Structured Clinical Interview for DSM IV (SCID: First, Spitzer, Gibbon, & Williams, 1995) was used for diagnosis in the majority of cases (n = 79). The remainder of patients were clinically diagnosed by an experienced psychiatrist from the Mood Disorders Program using a semi-structured clinical interview. All of the subjects had a primary diagnosis of current Major Depressive Disorder and were nonpsychotic. A subset of the SCID-diagnosed group (n = 11) along with 9 subjects with other diagnoses (principally anxiety disorders) were interviewed and rated simultaneously by two raters. In 19 out of 20 cases there was agreement on the primary diagnosis. Inter-rater reliability data are not available for the non-SCID patients. 2.2. Measures The following self report instruments were completed by all subjects. 1. Multidimensional Perfectionism Scale (MPS; Hewitt & Flett, 1991a). This is a 45-item questionnaire that generates 3 subscale scores: Self-oriented perfectionism (which involves the setting of unrealistic standards and perfectionistic striving for the self), socially prescribed perfectionism (which involves the belief that signi®cant others expect oneself to be perfect) and other oriented perfectionism (setting unrealistic standards for others). 2. Multidimensional Perfectionism Scale (MPS: Frost et al., 1990). This is a 35-item questionnaire with 6 subscales: concern over mistakes (re¯ecting negative reactions to mistakes), personal standards (setting high standards for self evaluation), parental expectations (the belief that one's parents set very high goals), parental criticism (the perception that one's parents were overly critical), doubts about actions (the tendency to doubt one's abilities) and organization (the importance placed on orderliness). 3. NEO-Five Factor Inventory (NEO-FFI: Costa & McCrae, 1992). The NEO-FFI is a 60item personality inventory that yields scores for 5 higher-order personality factors: neuroticism, extraversion, openness-to-experience, agreeableness and conscientiousness. 4. Depressive Experiences Questionnaire (DEQ: Blatt et al., 1976). The DEQ is intended to assess two distinct characterological con®gurations associated with depression Ð dependent and self-critical. The present study utilized a reconstructed and validated 19-item version of the DEQ (Bagby et al., 1994a). 5. The Beck Depression Inventory (BDI) is a 21-item measure of depression symptoms. It has been demonstrated to be a valid and reliable measure of depression (Beck et al., 1988). Scores for the BDI cognitive aective subscale were calculated as the sum of items 1, 2, 4, 9, 11, 12, 13, 15, 17 and 21; scores for the BDI cognitive distortions subscale were calculated
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Table 1 Correlations between Perfectionism dimensions and Depression Symptoms, Neuroticism and Extraversion BDI
Hewitt and Flett MPS Socially prescribed Self-oriented Other oriented
BDI cognitive distortions
BDI somatic complaints
HamD-17 Neuroticism Extraversion
0.33** 0.16 0.17*
0.55** 0.23** 0.25**
0.07 ÿ0.04 ÿ0.04
0.23* 0.19 0.26*
0.34** 0.17* 0.15
ÿ0.24** ÿ0.11 ÿ0.17*
Frost MPS Concern over mistakes 0.51** 0.40** ** Doubts about actions 0.31 0.28** * Parental criticism 0.21 0.09 Parental expectations 0.17* 0.12 Personal standards 0.05 0.05 Organization ÿ0.14 ÿ0.19*
0.57** 0.35** 0.32** 0.21* 0.10 ÿ0.06
0.08 ÿ0.02 0.01 0.02 ÿ0.15 ÿ0.06
0.28* 0.15 ÿ0.05 0.08 0.09 0.05
0.55** 0.56** 0.29** 0.13 0.03 ÿ0.23**
ÿ0.28** ÿ0.35** 0.00 0.05 0.12 0.21*
0.59**
0.07
0.66**
ÿ0.37**
DEQ Self-criticism
0.45** 0.19* 0.20*
BDI cognitive aective
0.55**
0.47**
n = 145 except for HamD-17 where n = 79.*p < 0.05,
**
0.32**
p < 0.01.
as the sum of items 3, 5, 6, 7, 8 and 14; scores for the BDI somatic complaints subscale were calculated as the sum of items 16, 18, 19 and 20 (based on Steer et al., 1987). 6. In addition to the self report measures, Hamilton Depression Ratings (HamD-17: Hamilton, 1960) were performed on a subset of 79 subjects using the Structured Interview Guide for the Hamilton Rating Scale (Williams, 1988).
3. Results The mean BDI score in the group was 30.0 (S.D. = 9.5) with a range of 112 to 52. The mean HamD-17 score was 22.1 (S.D. = 3.8) with a range of 10 to 30. Table 1 shows the correlations between the dierent perfectionism dimensions and BDI scores, BDI subscale scores, HamD-17 ratings and higher-order personality factors theoretically related to depression (neuroticism, extraversion). The eect size criteria speci®ed by Cohen (1992) can be used to describe the degree of correlation (medium rr 0.3, large r r0.5). In general, socially prescribed perfectionism, concern over mistakes, doubts about actions, and self-criticism, had 2
A BDI score of 11 is unusual for a patient with major depression; a review of this subject's record indicated that he was suering from a mild but de®nite MDE, and that the symptoms endorsed on his BDI corresponded to the symptoms found in a clinical interview. Thus, the BDI was considered to have been validly completed.
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medium to large correlations with BDI scores, particularly with the BDI cognitive distortions factor, had signi®cant though smaller correlations with HamD scores, were positively correlated with neuroticism, and were negatively correlated with extraversion. Speci®c hypotheses regarding the relative magnitudes of correlation coecients were tested using the method of Meng et al. (1992). We predicted that the perfectionism dimensions would show a stronger association with the BDI cognitive distortions subscale compared to the cognitive±aective and somatic complaints subscales. Numerically, the correlations between the perfectionism dimensions and BDI cognitive distortions were higher than those with BDI cognitive±aective in every instance. These dierences reached signi®cance for socially prescribed perfectionism (Z = 3.64, p < 0.001), concern over mistakes (Z = 2.91, p < 0.01), parental criticism (Z = 3.43, p < 0.001), and self criticism (Z = 2.13, p < 0.05). The correlations between the perfectionism dimensions and BDI cognitive distortions were substantially higher than those with BDI somatic complaints. These dierences reached signi®cance for socially prescribed perfectionism (Z = 4.93, p < 0.0001), self oriented perfectionism (Z = 2.56, p < 0.01), other oriented perfectionism (Z = 2.75, p < 0.01), concern over mistakes (Z = 5.10, p < 0.0001), doubts about actions (Z = 3.56, p < 0.001), parental criticism (Z = 2.99, p < 0.01) and self criticism (Z = 5.44, p < 0.0001). (The personal standards and organization subscales were not subjected to these comparisons as no pattern of signi®cant relationships with any of the depression scales was observed.) We also predicted that the correlations between perfectionism dimensions and HamD scores would be smaller than the corresponding correlations with BDI scores. Analyses for this hypothesis were limited to the 79 subjects for whom we had both BDI and HamD scores. Numerically, most (but not all) of the perfectionism dimensions were more strongly correlated with BDI scores. These dierences were signi®cant for socially prescribed perfectionism (Z = 2.42, p < 0.01), concern over mistakes (Z = 2.62, p < 0.01), parental criticism (Z = 3.01, p < 0.01), parental expectations (Z = 1.82, p < 0.05) and self criticism (Z = 2.71, p < 0.01). Table 2 shows the partial correlations between the perfectionism dimensions and depression scores, after controlling for neuroticism and extraversion. Although somewhat reduced, three of the four perfectionism variables continued to be correlated with BDI scores and the BDI cognitive distortions subscale in particular: socially prescribed perfectionism, concern over mistakes, and self-criticism3. To help clarify whether the above ®ndings re¯ect dierences between the perfectionism constructs (as opposed to dierences between the measures of the constructs), disattenuated correlations (rd) were computed [rd=r/Z(rxx.ryy), where r is the correlation coecient, rxx and 3
A series of hierarchical regression analyses were performed where dependent variables included BDI score, the BDI subscales, and HamD score. Neuroticism and extraversion scores were force-entered in the ®rst block and the three perfectionism dimensions with medium or large correlations with the dependent variable were force-entered in the second block. In each case, one or two of the same three perfectionism dimensions (socially prescribed perfectionism, concern over mistakes, and self-criticism) were signi®cant predictors in the regression equation and the others were not, but the same predictor variable(s) was not consistently identi®ed. We therefore chose not to present these results because they appeared to convey a misleading impression of speci®city in the relationship between perfectionism dimensions and the dierent depression measures.
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Table 2 Partial correlations between Perfectionism dimensions and Depression symptoms (Neuroticism and Extraversion partialled out) BDI
BDI cognitive aective
BDI cognitive distortions
BDI somatic complaints
HamD-17
Hewitt and Flett MPS Socially prescribed Self-oriented Other oriented
0.32** 0.08 0.10
0.16 0.06 0.07
0.45** 0.15 0.17*
0.04 ÿ0.08 ÿ0.08
0.18 0.17 0.24*
Frost MPS Concern over mistakes Doubts about actions Parental criticism Parental expectations Personal standards Organization
0.29** ÿ0.06 0.16 0.21* 0.06 0.02
0.15 ÿ0.07 0.00 0.13 0.07 ÿ0.05
0.38** 0.03 0.27** 0.23** 0.12 0.11
0.06 ÿ0.09 0.06 0.07 ÿ0.14 ÿ0.03
0.26* 0.09 ÿ0.08 0.09 0.11 0.12
0.34**
0.03
DEQ Self-criticism
0.27**
0.17*
n = 145 except for HamD-17 where n = 79.*p < 0.05,
**
0.32**
p < 0.01.
ryy are reliability coecients]. These results are presented in Table 3. As can be seen, the overall pattern of results does not dier substantially from that presented in Table 1. The distributions of all scale scores were evaluated for the presence of skew. Two of the distributions were signi®cantly negatively skewed (organization and neuroticism). Log transformations of these scale scores corrected the skew. The analyses presented in Tables 1 and 2 were then repeated with the log transformed data. Although there were minor changes in the magnitude of correlations and partial correlations involving these two variables, there was no substantial change in the observed pattern of results. The distributions of all scale scores were also evaluated for the presence of outliers. No signi®cant outliers were detected. Antidepressant medications were being taken by just over half of our study participants (74/ 145). Hypothetically the use of such treatments may have had a preferential eect in the treatment of certain kinds of depressive symptoms (e.g. neurovegetative symptoms). Therefore a comparison of antidepressant users/non users was conducted. No signi®cant dierences between groups was observed with regard to age, gender, depression scores or any of the perfectionism scale scores. Furthermore the pattern and magnitude of correlations between perfectionism dimensions and depression scores was essentially the same in the two groups. The relationships among the dierent perfectionism dimensions used in the study are shown in Table 4. As can be seen, the organization subscale of the Frost MPS shows the weakest correlations with other perfectionism subscales. Self-criticism showed large correlations with each of socially prescribed perfectionism, concern over mistakes and doubts about actions.
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Table 3 Disattenuated correlations (rd) between Perfectionism dimensions, Depression symptoms, N and E BDI
Hewitt and Flett MPS Socially prescribed Self-oriented Other oriented
BDI cognitive aective
BDI cognitive distortions
BDI somatic complaints
HamD-17 Neuroticism Extraversion
0.52 0.22 0.24
0.39 0.19 0.21
0.67 0.28 0.32
0.11 ÿ0.06 ÿ0.07
0.28 0.23 0.33
0.40 0.20 0.18
ÿ0.28 ÿ0.13 ÿ0.21
Frost MPS Concern over mistakes 0.59 Doubts about actions 0.38 Parental criticism 0.26 Parental expectations 0.20 Personal standards 0.06 Organization ÿ0.16
0.48 0.35 0.11 0.14 0.06 ÿ0.22
0.69 0.45 0.42 0.26 0.13 ÿ0.07
0.13 0.04 0.02 0.03 ÿ0.26 ÿ0.10
0.34 0.19 ÿ0.06 0.10 0.12 0.06
0.64 0.70 0.36 0.15 0.04 ÿ0.26
ÿ0.33 ÿ0.44 0.00 0.06 0.15 0.25
0.60
0.77
0.12
0.42
0.83
ÿ0.47
DEQ Self-criticism
0.68
n = 145 except for HamD-17 column n = 79.rd=r/Z(rxx.ryy), where r is the correlation coecient, rxx and ryy are reliability coecients.
Table 4 Correlations among perfectionism dimensions (1) Hewitt and Flett MPS (1) Socially prescribed (2) Self oriented (3) Other oriented Frost MPS (4) Concern over mistakes (5) Doubts about actions (6) Parental criticism (7) Parental expectations (8) Personal standards (9) Organization DEQ (10) Self-criticism N = 145, *p < 0.05,
**
(2)
(3)
± 0.61** 0.55**
± 0.58**
±
0.70** 0.46** 0.49** 0.49** 0.38** ÿ0.02
0.52** 0.43** 0.33** 0.46** 0.66** 0.27**
0.50**
0.29**
p < 0.01.
(4)
(5)
(6)
(7)
(8)
0.41** 0.32** 0.18* 0.26** 0.40** 0.15
± 0.55** 0.44** 0.46** 0.46** ÿ0.03
± 0.22** 0.16 0.24** ÿ0.10
± 0.62** 0.33** 0.12
± 0.50** 0.23**
± 0.28**
0.27**
0.61**
0.50**
0.25**
0.11
0.16
(9)
±
ÿ0.05
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4. Discussion The results of this investigation generally supported the study hypotheses. Three of the ten perfectionism dimensions examined consistently displayed correlations re¯ecting medium to large eect sizes with self-report depression symptoms. These were socially prescribed perfectionism, concern over mistakes and self criticism. Importantly, medium-sized correlations remained when the eects of neuroticism and extraversion were partialled out. As expected, the magnitude of correlations between (self-reported) perfectionism scores and observer-rated depression symptoms was less than that observed between perfectionism scores and self-reported depression symptoms. These dierences may simply be attributable to the reporting method (i.e. self vs. observer ratings). Our data also suggest an alternative explanation. The HamD scale strongly emphasizes somatic/vegetative symptoms in rating depression, and the somatic complaints factor of the BDI did not show a substantial relationship with any of the perfectionism dimensions. Thus, a weak relationship between perfectionism and the somatic manifestations of depression may explain the observed pattern of results. The BDI cognitive distortions subscale repeatedly showed larger correlations with perfectionism dimensions than did the BDI cognitive aective and somatic complaints subscales. This is consistent with the observation that perfectionistic beliefs commonly underlie distorted automatic thoughts in depression (e.g., Burns, 1980). Future research might determine whether persons scoring high in these perfectionistic dimensions also experience a qualitatively distinct form of depression, perhaps characterized by self-blame and guilt (i.e., pathoplastic eects of perfectionism on the depressive experience). Perhaps the most noteworthy observation in the present study is the great variability in the magnitude (and direction) of correlations between the perfectionism dimensions and depression symptoms. After controlling for the eects of higher-order personality variables related to depression (Clark & Watson, 1991), three speci®c forms of perfectionism showed moderate to large correlations with depression symptoms. In sharp contrast, personal standards and organization showed very small or inverse relationships with depression symptoms. These ®ndings might be re¯ective of a proposed distinction between positive/adaptive and negative/ maladaptive perfectionism that has been suggested by a number of authors (Frost et al., 1993; Slaney et al., 1995; Terry-Short et al., 1995). In studies of college students, both Frost et al. (1993) and Slaney et al. (1995) reported conceptually unambiguous 2 factor solutions of the Frost et al. (1990) and Hewitt and Flett (1991a) perfectionism subscales into positive achievement striving and maladaptive evaluation concerns. The positive factor in both studies included self-oriented perfectionism, other oriented perfectionism, personal standards and organization; each of these scales showed small to negative correlations with depression symptoms and neuroticism in the present study. The negative factor identi®ed by Frost et al. (1993) and Slaney et al. (1995) included socially prescribed perfectionism, concern over mistakes, doubts about actions, parental criticism and parental expectations; the ®rst three of these subscales showed at least medium sized (rr 0.3) correlations with BDI scores and neuroticism in the present study. Future work in the area of assessment might involve a more explicit distinction between adaptive and maladaptive dimensions of perfectionism, with the goal of more accurately identifying vulnerability to psychopathology.
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On the basis of such ®ndings, it is clear that distinguishing multiple dimensions of perfectionism is important in understanding the relationship between perfectionism and depressive symptoms. In comparison to the Hewitt and Flett MPS, little research on the relationship between the Frost et al. MPS and depression has been reported (apart from correlational studies in college students). The present results suggest at least two of the Frost et al. MPS dimensions (concern over mistakes and doubts about actions) appear as likely candidates for depression vulnerability factors. Further investigations of perfectionism and depression using the Frost et al. MPS are clearly warranted. Previous studies of self-criticism and depression have consistently identi®ed strong cross sectional correlations with depression symptoms (Blatt et al., 1982; Brown & Silberschatz, 1989; Nietzel & Harris, 1990). Longitudinal studies have also provided evidence that self criticism predisposes to the development of depression, and interacts with matched stresses (achievement related events) to predict depression (Hammen et al., 1985; Segal et al., 1992). In the present study self-criticism showed the numerically highest bivariate correlation with BDI scores of all the perfectionism variables. Thus, both the conceptual relationship between selfcriticism and other perfectionism dimensions (Blatt, 1995; Enns & Cox, 1997), and the similar magnitude of correlations with self and observer rated depression symptoms support the need for further studies comparing these alternative formulations. Though a cross-sectional correlation with depression symptoms may identify a personality trait as a potential vulnerability factor for depression (e.g., Nietzel & Harris, 1990), it has also been argued that a vulnerability factor for depression needs to be carefully distinguished from current manifestations of depression (e.g., Blaney & Kutcher, 1991). We were unable to identify any studies assessing the eect of the depressed state on the measurement of perfectionism, but several reports have indicated that self-criticism is state dependent (Klein et al., 1988; Franche & Dobson, 1992; Bagby et al., 1994b). This represents an important area for future study. Interestingly, in the present (and other) studies self-oriented perfectionism showed a relatively modest correlation with depression symptoms. Yet, a four-month longitudinal study of former depressed patients found that self-oriented perfectionism interacted with achievement stresses to predict time 2 depression (Hewitt et al., 1996). Thus, some perfectionism variables may only show a relationship with depression under conditions of matching stress. Coyne and Whien (1995) have emphasized another reason to assess stressors (social context) in studying the relationship between personality and depression. Personality measures are, of course, intended to tap an enduring trait, however, such measures may also re¯ect the eects of particular stresses in the individual's social context (e.g. a person who recently was ®red due to poor work performance may be expected to endorse a high level of concern over mistakes). In summary, the present study demonstrated that three perfectionism dimensions from three dierent psychometric measures are signi®cantly associated with both self and observer rated depression symptoms in patients with major depressive disorder. Previous prospective studies have provided some support for self-oriented perfectionism, socially prescribed perfectionism and self-criticism as vulnerability factors for depression. However, several of the Frost et al. (1990) perfectionism dimensions appear to be candidates worthy of further study as well. Further longitudinal studies of speci®c vulnerabilities to depression might bene®t from
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including a more comprehensive assessment of perfectionism with a variety of measures to compare competing conceptualizations of the perfectionism construct.
Acknowledgements Results of this research were presented at the annual conventions of the Association for Advancement of Behavior Therapy, New York City, November 1996, and the Canadian Psychiatric Association, September 1997.
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