Role of perfectionism and personality disorder features in response to brief treatment for depression.

Using data from the Treatment of Depression Collaborative Research Program (TDCRP), the authors compared the role of patients' perfectionism and features of personality disorder (PD) in the outcome of brief treatment for depression. Data were extracted as to patients' intake levels of symptoms; perfectionism; and PD features, measured as continuous variables, as well as their symptoms at termination; their contribution to the therapeutic alliance; and their satisfaction with social relations. Poorer therapeutic outcome was demonstrated for patients with elevated levels of perfectionism and odd-eccentric and depressive PD features. Patients' contribution to therapeutic alliance and satisfaction with social relations were predicted by perfectionism but not by PD features. Results highlight the central role played by patients' personality in the course of brief treatment for depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The destructiveness of perfectionism: Implications for the treatment of depression.

Reports in the public media indicate that intense perfectionism and severe self-criticism played a role in the suicide of three remarkably talented individuals. The role of perfectionism in these suicides is consistent with recent extensive investigations of aspects of perfectionism as well as further analyses of the NIMH Treatment of Depression Collaborative Research Program (TDCRP), indicating that intense perfectionism interfered significantly with therapeutic response in the various brief treatments for depression. Self-critical individuals, however, made substantial improvement in long-term intensive treatment. These findings suggest the value of considering psychopathology, especially depression, from a psychological rather than a symptomatic perspective; that different patients may be differentially responsive to various types of therapy; and that more extensive therapy may be necessary for many highly perfectionistic, self-critical patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

"Impact of perfectionism and need for approval on the brief treatment of depression: The National Institute of Mental Health Treatment of Depression Collaborative Research Program revisited": Correction.

Reports an error in the original article by S. J. Blatt et al (Journal of Consulting and Clinical Psychology, 1995[Feb], 63[1], 125–232. Corrections in Table 2, which presented correlations of 5 measures of therapeutic change at pretreatment with 4 outcome variables, resulted in reducing the size and significance of the correlations of pretreatment Social Adjustment Scale scores in predicting therapeutic change. (The following abstract of this article originally appeared in record 1995-25991-001). Patients in the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP) were administered at intake with the Dysfunctional Attitude Scale (DAS; A. N. Weissman & A. T. Beck 1978). Factor analyses of the DAS in the TDCRP data as well as in several independent samples reveal two primary factors: an interpersonal factor, Need for Approval, and a self-critical factor, Perfectionism. This study explored the hypotheses that these factors, assessed prior to treatment, would have differential interactions with the two forms of psychotherapy evaluated in the TDCRP as well as differential relationships to various outcome measures (depression, clinical functioning, and social adjustment). … (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relation of therapeutic alliance and perfectionism to outcome in brief outpatient treatment of depression.

Prior analyses of the National Institute of Mental Health Treatment of Depression Collaborative Research Program demonstrated that perfectionism was negatively related to outcome, whereas both the patient's perception of the quality of the therapeutic relationship and the patient contribution to the therapeutic alliance were positively related to outcome across treatment conditions (S. J. Blatt et al, see record 1996-02770-018; J. L. Krupnick et al, see record 1996-05271-014). New analyses examining the relations among perfectionism, perceived relationship quality, and the therapeutic alliance demonstrated that (a) the patient contribution to the alliance and the perceived quality of the therapeutic relationship were independent predictors of outcome, (b) perfectionistic patients showed smaller increases in the Patient Alliance factor over the course of treatment, and (c) the negative relation between perfectionism and outcome was explained (mediated) by perfectionistic patients' failure to develop stronger therapeutic alliances. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Interpersonal factors in brief treatment of depression: Further analyses of the National Institute of Mental Health Treatment of Depression Collaborative Research Program.

Previous analyses of data from the National Institute of Mental Health Treatment of Depression Collaborative Research Program indicate minimal differences in therapeutic outcome among 3 brief treatments for depression, but patients' pretreatment level of perfectionism had a significant negative relationship with residualized measures of clinical improvement. The present analyses indicate that the quality of the therapeutic relationship reported by patients early in treatment contributed significantly to the prediction of therapeutic change. The quality of the therapeutic relationship was only marginally predictive of therapeutic gain at low and high levels of perfectionism, but significantly predicted therapeutic gain at moderate levels of perfectionism. These findings suggest that the extensive efforts to compare different manual-directed treatments need to be balanced by commensurate attention to interpersonal dimensions of the therapeutic process. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relationship of perfectionism, depression, and therapeutic alliance during treatment for depression: Latent difference score analysis.

The authors examined the longitudinal relationship of patient-rated perfectionism, clinician-rated depression, and observer-rated therapeutic alliance using the latent difference score (LDS) analytic framework. Outpatients involved in the Treatment for Depression Collaborative Research Program completed measures of perfectionism and depression at 5 occasions throughout treatment, with therapeutic alliance measured early in therapy. First, LDS analyses of perfectionism and depression established longitudinal change models. Further LDS analyses revealed significant longitudinal interrelationships, in which perfectionism predicted the subsequent rate of depression change, consistent with a personality vulnerability model of depression. In the final LDS model, the strength of the therapeutic alliance significantly predicted longitudinal perfectionism change, and perfectionism significantly predicted the rate of depression change throughout therapy. These results clarify the patterns of growth and change for these indicators throughout depression treatment, demonstrating an alternative method for evaluating longitudinal dynamics in therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Perfectionism as a predictor of positive and negative psychological outcomes: Examining a mediation model in younger and older adults.

The relations between general perfectionistic tendencies as measured by R. 0. Frost, P. Marten, C. Lahart, and R. Rosenblate's (1990) Multidimensional Perfectionism Scale (MPS), stress, and psychological outcome were assessed among a sample of younger (M?=?20.00 years;n?=?270) and older adults (M?=?46.99 years; n?=?256). Results of conducting a series of path analyses examining a mediation model indicated that the influence of perfectionism on a measure of positive psychological outcome (viz., life satisfaction) was fully mediated by stress. In contrast, the influence of perfectionism on measures of negative psychological outcome (viz., negative mood and worry) were only partially mediated by stress. These pathanalytic findings were consistent across both age groups. Implications of the present findings for future research and intervention in working with perfectionistic clients are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Stress reactivity following brief treatment for depression: Differential effects of psychotherapy and medication.

Psychotherapy and medication treatments are both effective in reducing depressive symptoms. However, only psychotherapy provides an enduring effect by reducing depressive vulnerability following treatment termination. This differential efficacy may reflect mode-specific effects on the longitudinal relationship between depression and stress. The current study examined posttreatment data from 153 outpatients enrolled in the Treatment of Depression Collaborative Research Program. Longitudinal analyses using the latent difference score (LDS) framework (a structural modeling technique that combines features of latent growth curve and cross-lagged regression models) evaluated the temporal relationship between severity of depression and frequency of stressful life events, assessed by interviewers at treatment termination and at 6, 12, and 18 months following treatment. Results supported a stress reactivity model in that stressful events led to elevations in the rate of depression change. Furthermore, multigroup LDS analysis indicated that this longitudinal stress reactivity occurred only for outpatients in the medication conditions. Results demonstrate that the enduring impact of psychotherapy involves the development of enhanced resiliency to stressful life events. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The therapeutic relationship in the brief treatment of depression: Contributions to clinical improvement and enhanced adaptive capacities.

Using data from the National Institute of Mental Health Treatment for Depression Collaborative Research Program, the authors examined the impact on treatment outcome of the patient's perception of the quality of the therapeutic relationship and contribution to the therapeutic alliance. Shared variance with early clinical improvement was removed from these relationship measures. Multilevel modeling demonstrated that a perceived positive therapeutic relationship early in treatment predicted more rapid decline in maladjustment subsequent to the relationship assessment. This effect occurred equally across all 4 treatment conditions. A positive early therapeutic relationship also predicted better adjustment throughout the 18-month follow-up as well as development of greater enhanced adaptive capacities (EAC). Controlling a wide range of patient characteristics did not eliminate the effects of the therapeutic relationship on rate of improvement during treatment and on EAC. Thus, independent of type of treatment and early clinical improvement, the therapeutic relationship contributes directly to positive therapeutic outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Perfectionism and negative mood: The mediating roles of validation from others versus self.

This study examined a model in which the need for reassurance from others and the capacity for self-reinforcement mediated the relationships between two dimensions of perfectionism (evaluative concerns [EC] perfectionism and personal standards [PS] perfectionism) and anxiety and depression. Results from structural equation modeling of data from 295 college students from a large midwestern university indicated that the need for reassurance from others and the capacity for self-reinforcement fully mediated the relationship between EC perfectionism and anxiety as well as partially mediated the relationships between PS perfectionism and anxiety and depression. Moreover, 41% of the variance in anxiety and 50% of the variance in depression was explained by EC perfectionism, PS perfectionism, the need for reassurance from others, and/or the capacity for self-reinforcement. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive–behavior therapy versus pharmacotherapy: Now that the jury's returned its verdict, it's time to present the rest of the evidence.

Recent reanalyses suggest that pharmacotherapy was superior to cognitive–behavior therapy in the acute treatment of more severely depressed outpatients in the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP). At the same time, this finding was neither robust across sites within the TDCRP nor consistent with findings from other studies. D. F. Klein (1990) has argued that those other studies were inherently flawed because they did not include pill-placebo controls, an argument that he extended to drug–psychotherapy comparisons in the treatment of panic as well. It is agreed that the inclusion of such controls would have facilitated the interpretation of the findings, but it is not agreed that their omission rendered those studies uninterpretable. Cognitive–behavior therapy remains a viable alternative to pharmacotherapy in the treatment of depression and a particularly promising intervention in the treatment of panic disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Science is not a trial (but it can sometimes be a tribulation).

This article addresses a few of the most important issues raised by N. S. Jacobson and S. D. Hollon and by D. F. Klein (see record 1996-02770-007 and 1996-02770-008, respectively) about the findings of the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP). Questions addressed include the following: (a) What was the relative effectiveness of the treatments in the TDCRP for patients with severe depressive symptomatology? (b) Were there Treatment?*?Research Site interactions within the more severely depressed subsamples? (c) Was there adequate implementation of cognitive–behavior therapy (CBT) and other treatment conditions in the TDCRP? and (d) How do the relapse rates in the TDCRP compare with those in other studies? Current conclusions regarding all of these issues are presented. For the future, it is recommended that, rather than revisiting these issues again, researchers apply their energies to investigating new questions using the valuable TDCRP database. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predicting termination type from client-therapist agreement on the severity of the presenting problem.

Discrepancies between clients and therapists in their perceptions of the severity of the client's presenting problem were tested for their utility in predicting both premature and mutual termination. Eight problem types were examined, and analyses were conducted within a survival analysis framework. Across the majority of problem types, results indicated that greater discrepancies between clients and therapists lowered the odds of mutual termination; however, greater discrepancies did not in turn increase the odds of premature termination. Interaction tests of client-therapist discrepancy with a variable that changes over time, accruing number of sessions, offer some qualifications. In particular, in the case of two problem types--depression and family-of-origin--when large discrepancies occurred, the likelihood of premature termination maintained at an equal rate throughout treatment, whereas when discrepancies were moderate or absent, the likelihood of premature termination diminished. Implications for clinicians and researchers point to enhancement of the therapeutic alliance as a means of reducing the probability of premature termination and increasing the probability of mutual termination. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A preliminary study of perfectionism and loneliness as predictors of depressive and anxious symptoms in Latinas: A top-down test of a model.

In the present study, we used a top-down approach to examine perfectionism and loneliness as additive sociocognitive predictors of depressive and anxious symptoms in a sample of 121 Latina college students. Consistent with expectations, we found perfectionism and loneliness to be associated with both depressive and anxious symptoms. In addition, results of conducting hierarchical regression analyses indicated that certain dimensions of perfectionism, especially doubts about actions, accounted for significant variance in both depressive and anxious symptoms. Moreover, the inclusion of loneliness as a predictor was found to predict additional unique variance in both depressive and anxious symptoms beyond what was accounted for by perfectionism. Implications of the present findings for future research on negative affective conditions in Latinas are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Perfectionism: conceptual and clinical aspects

OBJECTIVE: Study of the concept of perfectionism and its phenomenology, etiology, and treatment. METHODS: Review of the literature, phenomenological, and-clinical analyses. RESULTS: The International Classification of Diseases introduced the notion of perfectionism into psychiatric discourse in 1977. In DSM-III, DSM-III-R, and DSM-IV, perfectionism is a diagnostic criterion of obsessive-compulsive disorder, but has never been defined in the psychiatric literature. We differentiate normal perfectionism and pathological perfectionism, which is of some psychiatric interest: normal perfectionism is manifested according to the aptness of the target and its sociocultural value, and is therefore selective and flexible, whereas pathological perfectionism is the compulsive pursuit of a performance level not required by the circumstances and idiosyncratic in nature. Its symptomatology may resemble that of obsessive-compulsive disorder, but is actually quite different: whereas obsessive-compulsive symptoms are absurd and the product of ego-dystonic compulsion, pathological perfectionism is experienced as a personal obligation, and retain an identifiable cultural objective. CONCLUSIONS: The phenomenology of the normal and abnormal manifestations of perfectionism is well defined. While pathological perfectionism and obsessive-compulsive disorder are similar and may even share a common etiology, they should be considered 2 distinct clinical entities. The therapeutic approaches to pathological perfectionism remain empirical.     

Perfectionism as a predictor of subsequent adjustment: Evidence for a specific diathesis–stress mechanism among college students.

The relations among perfectionism, stress, subsequent psychological symptoms, and hopelessness were examined among 215 college students. Hierarchical regression analyses were conducted to determine whether dimensions of perfectionism (P. Hewitt & G. Flett, 1991) predicted psychological symptoms and hopelessness (1 month later), and the extent to which stress scores added incremental validity to these predictions. Results indicated that socially prescribed perfectionism was a significant predictor of both adjustment measures. In addition, stress accounted for a significant amount of additional variance in predicting adjustment beyond perfectionism. Consistent with a diathesis–stress model, a significant Perfectionism × Stress interaction was found in predicting scores on adjustment measures beyond perfectionism and stress. However, this interaction was only found for socially prescribed perfectionism. Results provide support for a specific diathesis–stress mechanism and important implications for developing specific interventions in working with perfectionistic college students. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Dyadic perfectionism as a predictor of relationship continuity and distress among college students.

This study examined the nature and impact of dyadic perfectionism over a 3-month interval within a sample of 116 college students who were currently involved in an intimate heterosexual relationship. Dyadic perfectionism scores were stable and correlated as expected with scores on concurrent measures of adult attachment orientations and relationship satisfaction. Logistic regression analyses revealed that, controlling for initial commitment status and adult attachment orientations, Time 1 dyadic perfectionism scores significantly and uniquely predicted relationship continuity 3 months later. Lastly, controlling for social desirability, relationship commitment status, and Time 1 adult attachment orientation scores, Time 1 dyadic perfectionism scores also uniquely predicted Time 2 relationship distress. Findings provide additional evidence that dyadic perfectionism is a risk factor for relationship dysfunction. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Stages of change.

Empirical research on the stages of change has taken a number of tacks over the past 20 years. In this article, we review those published research studies that have directly examined the stages (precontemplation, contemplation, preparation, action, maintenance, and, termination) as they relate to treatment outcome, broadly defined. The cumulative evidence indicates that tailoring the therapy relationship and treatment intervention to the stage of change can enhance outcome, specifically in the percentage of patients completing therapy and in the ultimate success of treatment. Several limitations of this body of research are noted. We conclude by advancing therapeutic practices both for conventional psychotherapy with individual patients and for proactive recruitment of entire populations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The structure and temporal stability of the Child and Adolescent Perfectionism Scale.

In this study, the authors examined the factor structure and temporal stability of the Child and Adolescent Perfectionism Scale (CAPS; G. L. Flett, P. L. Hewitt, D. J. Boucher, L. A. Davidson, & Y. Munro, 1997) in 2 samples of adolescents (15–16 years old). In Sample 1 (n = 624), confirmatory factor analysis did not support a 2-factor structure (self-oriented and socially prescribed perfectionism). As in B. T. McCreary, T. E. Joiner, N. B. Schmidt, & N. S. Ialongo (2004), reanalysis suggested a 3-factor solution (i.e., socially prescribed perfectionism, self-oriented–Striving perfectionism, self-oriented–Critical perfectionism). The authors validated their 3-factor model in an independent replication sample (Sample 2; n = 514) and confirmed that the 3-factor structure was invariant across gender and time (test–retest over 6 months). Taking these analyses together, the authors concluded that their discriminant 3-factor structure is robust. Theoretical and clinical implications are discussed. More research on the predictive validity of the CAPS is suggested. (PsycINFO Database Record (c) 2010 APA, all rights reserved)