Perfectionism and Depression: Longitudinal Assessment of a Specific Vulnerability Hypothesis

Transcription

1 Journal of Abnormal Psychology Vol. 105, No Copyright 1996 by the American Psychological Association, Inc X/96/$3.00 Perfectionism and Depression: Longitudinal Assessment of a Specific Vulnerability Hypothesis Paul L. Hewitt University of British Columbia Gordon L. Flett York University Evelyn Ediger University of Winnipeg The authors tested whether perfectionism dimensions interact with specific stress to predict depression over time. A sample of 103 current and former patients completed measures of perfectionism and depression at Time 1 and measures of stress and depression 4 months later. After controlling Time 1 depression, self-oriented perfectionism interacted only with achievement stress to predict Time 2 depression. did not interact with achievement or social stress to predict Time 2 depression, but it did predict Time 2 depression as a main effect. The results provide support for the contention that perfectionism dimensions are involved in vulnerability to depression over time. Depressive disorders are recognized as among the most prevalent forms of psychopathology, and a goal among researchers is to identify factors that predispose people to these disorders. Most theorists (e.g., Beck, 1983; Blatt & Zuroff, 1992) have distinguished between personality vulnerability factors that involve achievement versus social concerns. Perfectionism is a personality variable of importance in depression, and the achievement and social distinction has been incorporated into the perfectionism construct (Frost, Marten, Lahart, & Rosenblate, 1990; Hewitt & Flett, 1991b). For instance, Hewitt and Flett (1991b) identified self-oriented perfectionism as an achievement-based dimension that involves the need for one's own perfection. In contrast, other-oriented perfectionism is an interpersonal dimension that involves the need for others to be perfect, and socially prescribed perfectionism is an interpersonal dimension that involves the belief that others expect perfection from oneself. Self-oriented and socially prescribed perfectionism are the dimensions most relevant to depression (Hewitt & Flett, 199la), and two mechanisms have been proposed to account Paul L. Hewitt, Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada; Gordon L. Flett, Department of Psychology, York University, Toronto, Ontario, Canada; Evelyn Ediger, Department of Psychology, University of Winnipeg, Winnipeg, Manitoba, Canada. This research was supported by Social Sciences and Humanities Research Council of Canada Grant and by a grant from the University of Winnipeg. We would like to thank the members of the Society for Depression and Manic Depression of Manitoba and Bill Ashdown for supporting this research, as well as Anita Delongis, Jack Rachman, and Lois Callander. Correspondence concerning this article should be addressed to Paul L. Hewitt, Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver, British Columbia, Canada V6T 1Z4. for this relationship (Hewitt & Flett, 1993). First, perfectionistic behavior can generate stress that stems, in part, from the tendency for perfectionists to evaluate stringently, focus on negative aspects of performance, and experience little satisfaction. Second, perfectionistic behavior can enhance the aversiveness of stress responses. This stems from equating perfect performance with self-worth whereby performances other than perfection are interpreted as failures and as indicators of worthlessness. As indicated, stress plays an important role in our model of perfectionism and depression. We have proposed that stressors that are congruent with a particular perfectionistic style are experienced as more aversive than noncongruent stressors, because the congruent stressors are ego involving and the aversive negative impact is therefore enhanced, leading to depression symptoms (Hewitt & Dyck, 1986; Hewitt & Flett, 1993). We suggested that because self-oriented perfectionism involves attaining self-related achievement goals, achievement stressors should be experienced as more aversive than other stressors. On the other hand, because socially prescribed perfectionism involves maintaining others' approval by being perfect, social stressors that impinge on one's ability to meet others' expectations may be experienced as more aversive than other stressors. Thus, self-oriented and socially prescribed perfectionism may be viewed as specific vulnerability factors that require congruent stressors to produce depression symptoms. Hewitt and Flett (1993) supported this in a sample of unipolar depressives: Selforiented perfectionism interacted only with achievement stress to predict concurrent depression, whereas socially prescribed perfectionism interacted only with social stress. A critical test for research on vulnerability factors is whether the personality styles predict depression longitudinally. If selforiented or socially prescribed perfectionism predispose individuals to depression, then perfectionism should confer a vulnerability that is evident over time when congruent stressors are 276

2 SHORT REPORTS 277 present. Flett, Hewitt, Blankstein, and Mosher (in press) provided some support for this model by demonstrating in stressed college students that both self-oriented and socially prescribed perfectionism were correlated with concurrent depression, but only self-oriented perfectionism predicted increases in depression over a 3-month period. Although congruent stress was not measured in the study, the findings suggest that self-oriented perfectionism may be relevant to depression concurrently and longitudinally, but that socially prescribed perfectionism may be relevant only for concurrent depression symptoms. Our goal was to assess whether self-oriented and socially prescribed perfectionism, in combination with congruent stressors, predict depression symptoms over time. This would provide further support for our contention that perfectionism acts as a vulnerability factor in depression. Participants Method The initial sample was composed of 121 patient members (84 women, 36 men, 1 not reported) of the Society for Depression and Manic Depression of Manitoba (SDMDM), a community organization providing advocacy and support to individuals who have or have had unipolar or bipolar depression and their families. The mean age of the sample was years(s > = 13.32); participants were predominantly White (83%), married or co-habiting (82%), and employed at least part-time (52%); and they reported having at least some high-school education (73%). All participants indicated that they had experienced depression or mania and received some inpatient or outpatient treatment: 80% were currently receiving medication treatment, and 46% were currently receiving psychological treatment. Although diagnostic interviews were not conducted, the use of cut-points on the General Behavior Inventory (GBI; Depue KJeiman, Davis, Hutchinson, & Krauss, 1985) showed that the sample comprised 33 individuals with chronic unipolar depression (mean unipolar symptoms = 32.00, SD = 5.57; mean bipolar symptoms = 9.15, SD = 3.81), 13 with chronic bipolar depression (mean unipolar symptoms = 35.46, SD = 5.95; mean bipolar symptoms = 20.23, SD = 3.63), and 75 with other or no disorders (mean unipolar symptoms = 8.09, SD = 7.11; mean bipolar symptoms = 2.87, SD = 3.32). The Beck Depression Inventory (BDI; Beck, Steer, & Garbin, 1988) scores differed among the groups, F(2, 118)= 14.29,p<. 001, with the unipolar(a/= 20.06, S > = 13.36)and bipolar groups (M = 19.85, SD = 15.57) scoring higher than the other disorders group (M = 9.26, SD = 8.24). Materials Multidimensional Perfectionism Scale (MPS). The MPS (Hewitt & Flett, 1991b) is composed of three subscales measuring self-oriented, other-oriented, and socially prescribed perfectionism. Participants rate their agreement with items using 7-point scales. The reliability and validity of the MPS have been demonstrated in clinical and nonclinical samples. For example, scores on the subscales are correlated with clinician ratings and with theoretically similar constructs and are not influenced by response biases (Flett, Hewitt, Blankstein, & Koledin, 1991; Hewitt & Flett, 199la; Hewitt, Flett, Turnbull-Donovan, & Mikail, 1991).' BDI. The BDI is a 21-item instrument measuring the behavioral, cognitive, and somatic symptoms of depression (Beck et al., 1988). It is used widely as a measure of severity of depression symptoms. Its reliability and validity have been summarized (Beck et al., 1988). Life Events Inventory (LEI). The LEI (Cochrane & Robertson, Table 1 Intercorrelations, Means, and Standard Deviations of the Perfectionism, Life Events, and Depression Measures Measure Self-l 2. Soc-1 3. BDI-1 4. BDI-2 5. ACH-2 6. INT-2 M SD.92.57***.38***.32***.16.42*** ***.45***.12.39*** ***.18.27** **.50*** * , Note. N= 103. Zero-order correlations are presented below the diagonal, and alphas are presented on the diagonal. Self = self-oriented perfectionism; Soc = socially prescribed perfectionism; BDI = Beck Depression Inventory; ACH = Achievement Life Events; INT = Interpersonal Life Events; 1 = Time 1; 2 = Time 2. *p<.05. **p<.q\. ***p< ) is a 55-item measure of stress experienced in relation to life events. We scored only the frequency of negative events, and three raters rated the items on achievement and interpersonal themes. Events that were rated with 100% agreement were retained, resulting in 10 achievement (e.g., unemployment, homelessness) and 26 interpersonal events (e.g., death of family member, increased family arguments). The two item sets did not differ in terms of overall stress severity ratings provided by Cochrane and Robertson (M = 56.80, SD = 13.14,andA/= 56.92, SD = 14). Furthermore, the proportion of potentially controllable events, as rated by three individuals, did not differ (70% vs. 69%, respectively). Instructions specified that only events occurring since the initial assessment should be endorsed. Procedure In November 1992, 403 SDMDM members (patient and affiliates) were mailed a consent form, the MPS and BDI, and an endorsement letter from the SDMDM director. The letter indicated that only patients who had been diagnosed with unipolar or bipolar depression were to complete the package. A total of 156 packages were returned; 21 packages were uncompleted, 13 packages were completed by nonpatient members, and 1 had excessive missing data, leaving a total 121 participants. Four months later, the participants were sent the BDI and LEI. A total of 103 participants returned the materials. 2 Results The means, standard deviations, correlations, and alphas for all measures are shown in Table 1. Both the MPS subscales and BDI had adequate reliabilities, although the alphas for the life events measures were quite low. This was not unexpected, because each event category contains discrete events that reflect 1 Because other-oriented perfectionism has not been shown to be relevant to unipolar depression, we report only information pertaining to self-oriented and socially prescribed perfectionism. 2 The 18 participants who did not complete the Time 2 assessment did not differ from the 103 participants who did complete the Time 2 assessment in terms of depression symptoms or diagnoses, age, education, gender, or marital status.

3 278 SHORT REPORTS Table 2 Hierarchical Regression Analyses Predicting Time 2 Depression With Time 1 Perfectionism and Time 2 Achievement and Interpersonal Stress Variable R 2 change df Achievement events * 4.31* Interpersonal events , *** 0.52 Achievement events Interpersonal events ** 4.71* ** 19.28*** 1.25 Note. N = 103. BDI = Beck Depression Inventory. *p<.05. **p<. 01. ***p<.001. either the achievement or interpersonal theme. The correlations among the measures show that the two relevant perfectionism subscales were correlated with depression at both time points. Furthermore, both event measures were correlated with Time 2 BDI, but only interpersonal events were correlated with Time 1 BDI. Time 1 and Time 2 BDI were highly correlated. The specific vulnerability hypothesis was addressed with a set of hierarchical regression analyses with either achievement or interpersonal events as the stress measure. Time 2 BDI scores were predicted in each analysis, and the variables were entered sequentially: Time 1 BDI, perfectionism dimension, life event dimension, and the perfectionism by life event product vector. 3 With respect to self-oriented perfectionism (top of Table 2), as well as Time 1 depression and achievement events, the interaction of self-oriented perfectionism and achievement events was significant. The significant interaction indicates that the relationship between achievement stress and depression changes depending on the level of self-oriented perfectionism. To clarify the nature of the interaction, we calculated the slopes of the regression of Time 2 depression on achievement events at three levels of self-oriented perfectionism, one standard deviation above the mean (high), the mean (medium), and one standard deviation below the mean (low; Cohen & Cohen, 1983,p. 323). The only significant slope was for the high value (b = 3.02, / = 3.60, p <.001). Neither the slope for the medium value (b = 1.26, t = 1.62, ns) nor the low value (b = -0.48, / = -0.05, ns) was significant. Only patients high in self-oriented perfectionism experienced increased depression as achievement events increased. Finally, self-oriented perfectionism did not interact with interpersonal events to predict Time 2 depression. Other results (bottom of Table 2) showed that Time 1 depression, socially prescribed perfectionism, and achievement events predicted Time 2 depression as main effects, but the interaction of socially prescribed perfectionism and achievement events was not significant. In addition, although the main effects for socially prescribed perfectionism and interpersonal events were significant, their interaction was not significant. Discussion The present study investigated the role of perfectionism as a vulnerability factor in depression. We found that self-oriented perfectionism interacted only with achievement stress to predict depression symptoms over time but that socially prescribed perfectionism predicted depression symptoms only as a main effect. This suggests that self-oriented perfectionism may be the perfectionism dimension that is most important as a stressvulnerability factor in depression (Hewitt & Flett, 1993). The findings are consistent with Hammen, Ellicott, and Gitlin (1989) indicating that achievement-related variables and stress are important in predicting future levels of depression. Our current results and past findings (Flett et al., in press; Hewitt & Dyck, 1986; Hewitt & Flett, 1993; Hewitt, Mittlestaedt, & Wollert, 1989) suggest that self-oriented perfectionism may capture the achievement-based vulnerability to de- 3 As suggested by Cohen and Cohen (1983), tests for homogeneity of covariance were conducted for each of the regression equations. The assumption was not violated in any of the equations.

4 SHORT REPORTS 279 pression more consistently than other autonomy-related constructs (see Nietzel & Harris, 1990). Clearly, there are similarities between self-oriented perfectionism and autonomy (Hewitt & Flett, 1993; Robins & Luten, 1991), but self-oriented perfectionism encompasses highly punitive responses to the self when perfection is not attained and has more pervasive qualities with extreme standards and evaluations applied to a wide variety of situations. A goal for future research is to examine perfectionism and other traits and their relative importance in depression over time. In contrast to the results obtained with self-oriented perfectionism, analyses showed that socially prescribed perfectionism did not interact with specific stress to predict depression over time. However, the main effect of socially prescribed perfectionism did predict increased levels of depressive symptoms over time. In earlier research, it was found that socially prescribed perfectionism was the most robust predictor of BDI scores when considered within the context of other personality factors such as sociotropy, autonomy, self-criticism, and dependency (Hewitt & Flett, 1993). The evidence indicates that socially prescribed perfectionism is a social-cognitive factor that may contribute to depression symptoms, but it does not moderate the association between life stress and depression consistently. Several limitations should be acknowledged. First, the sample was not a homogeneous diagnosed group of depressed individuals, but a heterogeneous community sample of individuals who experienced depression. Thus, we cannot be certain that our results will generalize specifically to a particular depression group. Moreover, Depue et al. (1985) indicate that the other disorders category, based on GBI scores, can include subclinical or single episode affective disorders or nonaffective disorders; however, the current methodology does not permit determining the specific disorders in this group. Although all participants reported being diagnosed and treated for depression at some point, the study would have been strengthened had structured interviews been conducted. Second, using a mail-out methodology precludes being certain that participants completed the scales as instructed. Third, the use of self-report stress questionnaires has been criticized on numerous grounds. These measures can be influenced by perceptual and response biases and by faulty memory, which can inflate the inaccuracy of event reporting and impact ratings (McQuaid et al., 1992; Raphael, Cloitre, & Dohrenwend, 1991). Interviewer-based measures can provide more precise measurement of stressful events. Fourth, the current results are relevant for predicting changes in severity of depression symptoms over time and not initial onset or relapse of specific episodes. Finally, the interaction of self-oriented perfectionism and achievement stress accounted for a significant but relatively small amount of variance in Time 2 depression. Finding a significant interaction in analyses such as these is difficult, and, McClelland and Judd (1993) indicated that such interactions typically account for 1-3% of variance. Furthermore, Champoux and Peters (1987, p. 253) stated that the amount of variance an interaction term accounts for is an inadequate indicator of the magnitude of the interaction effect and that the calculation of slopes, as was done in this study, is a more appropriate way to estimate interaction effect sizes. Thus, we believe the significant interaction in this work is meaningful both statistically and substantively. In summary, the findings provided further evidence for the role of perfectionism in depressive vulnerability. Our data provided additional support for the contention that perfectionism dimensions may function as important factors in unipolar depression that is evident over time. References Beck, A. T. (1983). Cognitive therapy of depression: New perspectives. In P. J. Clayton & J. E. Barrett (Eds.), Treatment of depression: Old controversies and new approaches (pp ). New York: Raven Press. Beck, A. T., Steer, R. A., & Garbin, M. G. (1988). Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clinical Psychology Review, 8, Blatt, S., & Zuroff, D. (1992). Interpersonal relatedness and self definition: Two prototypes for depression. Clinical Psychology Review, 12, Champoux, J., & Peters, W. (1987). Form, effect size and power in moderated regression analysis. Journal of Occupational Psychology, 60, Cochrane, R., & Robertson, A. (1973). The Life Events Inventory: A measure of the relative severity of psycho-social stressors. Journal of Psychosomatic Research, 17, Cohen, J., & Cohen, P. (1983). Applied multiple regression/correlation analysis for the behavioral sciences. Hillsdale, NJ: Erlbaum. Depue, R., Kleiman, R., Davis, P., Hutchinson, M., & Krauss, S. (1985). The behavioral high-risk paradigm and bipolar affective disorder, VIII: Serum free cortisol in nonpatient cyclothymia subjects selected by the General Behavior Inventory. American Journal of Psychiatry, 142, Flett, G. L., Hewitt, P. L., Blankstein, K. R., & Koledin, S. (1991). Dimensions of perfectionism and irrational thinking. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 9, Flett, G. L., Hewitt, P. L., Blankstein, K., & Mosher, S. (in press). Perfectionism and life events in vulnerability to depression. Current Psychology. Frost, R. O., Marten, P., Lahart, C, & Rosenblate, R. (1990). The dimensions of perfectionism. Cognitive Therapy and Research, 14, Hammen, C., Ellicott, A., &Gitlin, M. (1989). Vulnerability to specific life events and prediction of course of disorder in unipolar patients. Canadian Journal of Behavioural Science, 21, Hewitt, P. L., & Dyck, G. D. (1986). Perfectionism, stress, and vulnerability to depression. Cognitive Therapy and Research, 10, Hewitt, P. L., & Flett, G. L. (1991a). Dimensions of perfectionism in unipolar depression. Journal of Abnormal Psychology-101. Hewitt, P. L., & Flett, G. L. (1991 b). Perfectionism in the self and social contexts: Conceptualization, assessment, and association with psychopathology. Journal of Personality and Social Psychology, 60, Hewitt, P. L., & Flett, G. L. (1993). Dimensions of perfectionism, daily stress, and depression: A test of the specific vulnerability hypothesis. Journal of Abnormal Psychology, 102, Hewitt, P. L., Flett, G. L., Turnbull-Donovan, W., & Mikail, S. (1991). The Multidimensional Perfectionism Scale: Reliability, validity, and psychometric properties in psychiatric sample. Psychological Assessment, 3, Hewitt, P. L., Mittelstaedt, W., & Wollert, R. (1989). Validation of a measure of perfectionism. Journal of Personality Assessment, 53,

5 280 SHORT REPORTS McClelland, G., & Judd, C. (1993). Statistical difficulties of detecting interactions and moderator effects. Psychological Bulletin, 114, McQuaid, J., Monroe, S., Roberts, J., Johnson, S., Garamoni, G., Kupfer, D., & Frank, E. (1992). Toward the standardization of life stress assessment: Definition discrepancies and inconsistencies in methods. Stress Medicine, 8, Nietzel, M. T, & Harris, M. J. (1990). Relationship of dependency and achievement/autonomy to depression. Clinical Psychology Review, 10, Raphael, K.G., Cloitre, M., & Dohrenwend, B.P. (1991). Problems of recall and misclassification with checklist methods of measuring stressful life events. Health Psychology, 10, Robins, C. J., & Luten, A. G. (1991). Sociotropy and autonomy: Differential patterns of clinical presentation in unipolar depression. Journal of Abnormal Psychology, Received August 9, 1994 Revision received May 17, 1995 Accepted June 22, 1995