Perfectionism and depressive symptoms 3 years later: negative social interactions, avoidant coping, and perceived social support as mediators

Abstract

Although research has demonstrated perfectionism to have a negative impact on the treatment of depression, little research has examined the mechanisms or processes through which perfectionism predicts subsequent depressive symptoms in clinical populations over time. Using data from a prospective, 3-year study of a clinical sample (N = 96), hierarchical regression analyses indicated that perfectionism, assessed by the Dysfunctional Attitude Scale (Weissman AN, Beck AT. Development and validation of the Dysfunctional Attitude Scale: a preliminary investigation. Paper presented at the 86th annual convention of the American Psychological Association, Toronto, Ontario, Canada; 1978), is distinguished from major depression and neuroticism for its relations to depressive symptoms and interpersonal maladjustment 3 years later. Drawing from the model of Dunkley et al (J Couns Psychol 2000;47:437-53), path analysis indicated that Dysfunctional Attitude Scale perfectionism was related to depressive symptoms 3 years later through a number of persistent maladaptive tendencies, including negative social interactions, avoidant coping, and negative perceptions of social support.

Introduction

In the past decade, perfectionism, assessed by the Dysfunctional Attitude Scale (DAS) [1], has emerged as an important cognitive personality factor that is relatively resistant to change [2] and has a negative impact on the treatment of depression [3], [4], [5]. Although research has demonstrated DAS perfectionism to be an important patient variable that influences treatment process and outcome, and is a factor in depression maintenance, little research has examined the mechanisms or processes through which this variable predicts subsequent depressive symptoms in clinical populations over time.

In considering why perfectionists are prone to experience depressive symptoms, Dunkley, Blankstein, and colleagues [6], [7], [8] have distinguished between self-critical (SC) and personal standards (PS) dimensions of perfectionism. Contrary to the prevailing assumption that DAS perfectionism primarily refers to high PS and motivation to attain perfection [9], DAS perfectionism recently has been demonstrated to more closely reflect SC perfectionism than PS perfectionism [10], [11]. In relation to the 5-factor model of personality [12], DAS perfectionism and other SC perfectionism measures have been related to neuroticism, introversion, and antagonism, whereas PS perfectionism measures are most closely associated with conscientiousness [13], [14], [15]. DAS perfectionism also has a stronger, more consistent relation with depressive symptoms than do measures that represent PS perfectionism [10], [11], similar to measures that reflect the SC perfectionism dimension [16], [17]. Thus, we regarded SC perfectionism rather than PS perfectionism to be pertinent to a consideration of why DAS perfectionism might predict later depressive symptoms.

Dunkley et al [6], [8] emphasized 3 critical mediators to explain the relation between SC perfectionism and depressive symptoms. Self-critical perfectionism influences both actual and perceived daily stress (or hassles), avoidant coping, and low social support, which, in turn, predict depressive symptoms. First, SC perfectionists are assumed to generate high levels of daily stress because they engage in rigorous self-evaluations and magnify the negative aspects of events such that even mundane trials can be interpreted as major threatening stressors [18]. Self-critical perfectionists also experience high levels of daily stress because they are concerned about rejection and the loss of respect from others. This becomes manifested in a defensive interpersonal style that elicits actual negative reactions from other people [19], [20], [21], [22]. Second, SC perfectionists are assumed to have an avoidant coping style, which stems from their preoccupation with their deficiencies and lack of confidence in their abilities in handling stressful situations [8]. Self-critical perfectionists' tendency to engage in avoidant coping undercuts alleviation of the depressive symptoms associated with stressful situations [23]. Third, SC perfectionists perceive that others are unwilling or unavailable to help them in times of stress. Thus, SC perfectionists lack a critical buffer against the experience of depressive symptoms [24].

In summary, SC perfectionists are believed to be prone to experience depressive symptoms because they have a tendency to experience high levels of daily stress (eg, negative social interactions), give up or disengage from stressful situations, and believe they have less social support available to them in times of stress [6], [8]. In a cross-sectional study, Dunkley et al [6] used structural equation modeling to cross-validate a model in which SC perfectionism (referred to as evaluative concerns perfectionism in that article) was related to hassles, avoidant coping, and low perceived social support, which, in turn, were all uniquely related to depressive symptoms and fully explained the relation between SC perfectionism and depressive symptoms. Whereas Dunkley et al [6] assessed these mediators as stable, traitlike characteristics of perfectionism using retrospective, dispositional self-report measures, Dunkley et al [8] performed a more rigorous test of the model by aggregating situation-specific, daily assessments over a 7-day period. Dunkley et al [8] demonstrated that high daily stress, avoidant coping, and low perceived social support were pervasive across a variety of stressful situations for SC perfectionists and explained SC perfectionism's association with high negative affect and low positive affect, a combination that has been linked to depression.

The present study draws from the final cross-validated model of Dunkley et al [6] to explain the relation between DAS perfectionism and later depressive symptoms but expands on this study in 5 ways. First, because the findings of Dunkley et al [6] were based on a college student population, we examined these hypotheses in a clinical sample. This is important because the generalizability of findings from college student populations to clinical populations continues to be a contentious issue [25]. Second, in considering daily stress, we focused on negative social interactions, a construct that is conceptually and empirically similar to but distinguishable from hassles [26]. The negative effect of perfectionism on therapeutic outcome was mediated by perfectionists' inability to contribute to the therapeutic alliance [27] and their dissatisfaction with social relations [28].

Third, although Dunkley et al [8] examined stress, avoidant coping, low perceived social support, and depressive affect as stable, traitlike characteristics of SC perfectionism over the period of 1 week, further tests of the relation between perfectionism and maladaptive functioning over a substantially longer period are needed. Data from the Collaborative Longitudinal Personality Disorders Study (CLPS) [29] were used to test our hypotheses over a 3-year period. This sample of patients, most of whom were characterized by a persisting pattern of maladaptive traits and had been in treatment at entry to the study, represented a unique opportunity to examine traitlike qualities as explanations for the relation between perfectionism and later depressive symptoms.

Fourth, an important issue is the unique predictive utility of personality variables independent of their overlap with depression [22], [30], [31]. We controlled for the presence of major depression at time 1 in examining the relation between perfectionism and maladjustment at time 2 three years later. Finally, theoretical writings have concentrated on perfectionism as a pervasive neurotic style [32], [33], [34]. There is a need to demonstrate the unique contribution or incremental predictive validity of specific traits such as perfectionism over and above broader source traits such as neuroticism [22], [30], [35]. Thus, we sought to distinguish perfectionism from neuroticism in its unique relations with later negative social interactions, avoidant coping, perceived social support, and depressive symptoms. Previous studies have distinguished SC perfectionism measures from neuroticism for unique relations with, for example, negative interpersonal traits [13], [14] and depressive symptoms [17], [22], [36], [37].

In summary, we examined negative social interactions, avoidant coping, and low perceived social support as harmful aspects of SC perfectionism that explain the relation between DAS perfectionism and subsequent depressive symptoms 3 years later in a clinical sample. The findings of this study might provide pointers to influential maintaining processes and could contribute to identifying specific targets for clinical interventions across a broad range of clinical entities. Fig. 1 depicts the hypothesized relations based on the previous theoretical discussion and the final structural model of Dunkley et al [6] for the mediation of subsequent depressive symptoms: (a) time 1 DAS perfectionism will predict avoidant coping, low perceived social support, and negative social interactions at time 2; and (b) avoidant coping, perceived social support, and negative social interactions will predict depressive symptoms at time 2. We also tested 3 additional hypotheses: (1) avoidant coping elicits criticism from network members and contributes to high levels of negative social interactions [38]; (2) negative social interactions reduce perceptions of support availability [26]; and (3) low perceptions of social support trigger demoralization and avoidant coping [24]. Finally, an exploratory aspect of the modeling was to examine the relative predictive validity of time 1 DAS perfectionism controlling for the effects of time 1 major depression and neuroticism. Thus, time 1 major depression and neuroticism were included in the model and tested as relative predictors of negative social interactions, avoidant coping, perceived social support, and depressive symptoms at time 2. The major depression and neuroticism variables and their combined 8 tested paths are not shown in Fig. 1 to distinguish these exploratory tests from the hypothesized relations based on theory and previous findings [6] to be confirmed in the present clinical sample.