Abstract
Objective
To measure the association of perfectionism with obsessive-compulsive and depressive symptoms in children and adolescents with obsessive-compulsive disorder (OCD).
Method:
Sample consisted of 94 youth (44 boys, 49 girls; mean age = 13.2 y, SD = 2.5 y) with a DSM-IV diagnosis of OCD. Perfectionism beliefs were measured with both the Adaptive/Maladaptive Perfectionism Scale (AMPS) and a 14-item version of the Child and Adolescents Perfectionism Scale (CAPS-14). Using a hierarchical linear-regression model, we measured the association of perfectionist beliefs with severity of OCD and depressive symptoms.
Results:
Both AMPS and CAPS-14 scores were associated with the severity of OCD symptoms in our sample. In addition, CAPS-14 scores were associated with the severity of depressive symptoms, even when OCD symptoms were taken into account.
Conclusions:
Our findings lend further support to the hypothesis that perfectionism in youth with OCD is associated with variation in the severity of OCD and depressive symptoms.
Keywords: perfectionism, children, adolescents, obsessive-compulsive disorder, depression
Résumé
Objectif:
Mesurer l’association du perfectionnisme avec les symptômes obsessionnels-compulsifs et dépressifs chez les enfants et les adolescents souffrant du trouble obsessionnel-compulsif (TOC).
Méthode:
L’échantillon consistait en 94 adolescents (44 garçons, 49 filles; âge moyen = 13,2 ans, ET = 2,5 ans) ayant reçu un diagnostic de TOVC du DSMIV. Les croyances perfectionnistes ont été mesurées à l’aide de l’échelle de perfectionnisme adapté/mésadapté (AMPS) et d’une version en 14 items de l’échelle de perfectionnisme des enfants et des adolescents (CAPS-14). Un modèle hiérarchique de régression linéaire a servi à mesurer l’association des croyances perfectionnistes avec la gravité du TOC et des symptômes dépressifs.
Résultats:
Les scores à l’AMPS et à la CAPS-14 étaient associés à la gravité des symptômes du TOC dans notre échantillon. En outre, les scores à la CAPS-14 étaient associés à la gravité des symptômes dépressifs, même quand les symptômes du TOC étaient pris en compte.
Conclusions:
Nos résultats renforcent l’hypothèse selon laquelle le perfectionnisme chez les adolescents souffrant du TOC est associé à une variation de la gravité du TOC et des symptômes dépressifs.
Keywords: perfectionnisme, enfants, adolescents, trouble obsessionnel-compulsif, dépression
Introduction
Perfectionism in obsessive-compulsive disorder
Obsessive-compulsive disorder (OCD) is a common, severe neuropsychiatric disorder with typical onset in youth (childhood and adolescence) (Geller et al., 2000). OCD is characterized by distressing obsessions (repetitive, intrusive thoughts, images or impulses) and compulsions (repetitive behaviors or mental activities). Youth with OCD have major functional impairment at home, school, and in social settings (Valderhaug & Ivarsson, 2005).
OCD has been historically linked to perfectionism. Perfectionism can be either adaptive or maladaptive (Rice & Preusser, 2002). People with adaptive perfectionism strive for order or organization, pursue attainable goals, and demonstrate good stress and affect management when their expectations are not met (Libby, Reynolds, Derisley, & Clark, 2004). In contrast, those with maladaptive perfectionism set goals that are unrealistic (Frost, Marten, Lahart, & Rosenblate), resulting in self-criticism and low self-esteem (Blatt, Zuroff, Bondi, Sanislow, & Pilkonis, 1998). Recent studies on the assocation of OCD and perfectionism in adults have yielded inconsistent results (Baptista, Magna, McKay, & Del-Porto, 2011; Taylor, McKay, & Abramowitz, 2005).
Perfectionism in youth with OCD
There is evidence (Jacobs et al., 2009) that maladaptive perfectionism may impede response of adolescents to cognitive-behavior therapy (CBT), the most-effective intervention in pediatric OCD (Pediatric OCD Treatment Study (POTS) Team, 2004). However, very few studies on the association of OCD and perfectionism in youth have been performed. Two existing self-report measures of perfectionism for youth, the Child and Adolescent Perfectionism Scale (CAPS; Flett, Hewitt, Boucher, Davidson, & Munro, 1997) and the Adaptive/Maladaptive Perfectionism Scale (AMPS; Rice & Preusser, 2002) are adaptations of multidimensional instruments used to measure perfectionism in adults (Frost et al., 1990; Hewitt, Flett, Turnbull Donovan, & Mikail, 1991). Although both CAPS and AMPS include adaptive and maladaptive perfectionism subscales, they measure different perfectionism constructs. Whereas CAPS focuses on differences between internally motivated and socially prescribed goals, the AMPS measures cognitive dimensions related to the concept of perfectionism.
To the best of our knowledge, only one published study of child and adolescents OCD has relied on either the CAPS or the AMPS. Ye and colleagues (Ye, Rice, & Storch, 2008) studied 31 youth with OCD and reported that two AMPS subscales, Contingent self-esteem and sensitivity to mistakes, were significantly associated with increased OCD symptom severity. Libby et al. (Libby et al., 2004) compared 28 youth with OCD with 62 controls, but the study had used the Multidimensional Perfectionism Scale (MPS) (Frost et al., 1990), a scale developed for use in adults. Thus, although there is sufficient evidence of the utility of studying the clinical aspects of perfectionism in adults, only scarce data exists on the association of perfectionism and OCD symptoms in youth.
The present study
The underlying hypothesis of the study is that the study of perfectionism in youth with OCD has potential clinical relevance. With this in mind, the aim of the study was to measure the association of perfectionism with the severity of OCD and depressive symptoms in a sample of youth with OCD using both the CAPS and the AMPS. The primary hypothesis was that the severity of OCD symptoms would be significantly and positively associated with perfectionism measures. The secondary hypothesis was that maladaptive perfectionism would significantly account for the severity of depressive symptoms in youth with OCD.
Methods
Participants
Participants were a consecutive, single-site sample of youth who were seen for a consultation at the Pediatric OCD Consultation Team between April 2010 and March 2013. Inclusion criteria were a DSM-IV diagnosis of OCD and age between 9 and 17 years. Exclusion criteria included current diagnosis of bipolar, psychotic or autism spectrum disorders. Children with reading disability or difficulty reading the questionnaires had these read to them by our research assistant.
Procedure
The local Research Ethics Board approved the study. We obtained written informed consent from parents of all participants. In addition, written informed consent and assent were obtained from youth ≥16 and youth <16 years of age, respectively. Participants completed self-report questionnaires before the consultation. DSM-IV Diagnoses were determined with the Schedule for Affective Disorders and Schizophrenia for School-Age Children – Present Version (K-SADS-P; Kaufman et al., 1997).
Measures
Perfectionism was measured using a version of the CAPS (CAPS-14; O’Connor, Dixon, & Rasmussen, 2009) and the AMPS self-report instruments. In the original 22-item CAPS, youth are asked to rate their agreement with each item on a scale ranging from 1 (false – not at all true of me) to 4 (very true of me). CAPS differentiated self-oriented perfectionism (SOP) from socially prescribed perfectionism (SPP). SOP is defined as a strong internal motivation to be perfect, all-or-nothing thinking and expectations of high achievement. SPP is the generalized belief that others are imposing unrealistic demands on the self. High SOP and SPP scores have been associated with distress and maladjustment in youth (Boergers, Spirito, & Donaldson, 1998).
Factor analyses of the CAPS (McCreary, Joiner, Schmidt, & Ialongo, 2004; Rice & Preusser, 2002) did not support the two-factor solution (i.e., SOP and SPP) (O’Connor et al., 2009). Instead, an abbreviated 14-item version (CAPS-14; O’Connor et al., 2009) provided an optimal three-factor solution that was stable across sex and time in two separate groups (624 and 737 adolescents). The CAPS-14 retains the SPP construct, but differentiates SOP into adaptive self-oriented striving perfectionism ([SOSP], defined as positive striving for perfectionism) and maladaptive self-oriented critical perfectionism ([SOCP], defined as self-criticism). Indeed, evidence suggests that SOP is not homogenous (Dunkley, Blankstein, Masheb, & Grilo, 2006).
The AMPS (Rice & Preusser, 2002) is a 27-item self-report scale that measures four perfectionism dimensions:
sensitivity to mistakes (negative emotions associated with making mistakes);
contingent self-esteem (task-based feelings and self-evaluation);
compulsiveness (preferences for order and organization; deliberate orientation on tasks); and,
need for admiration (need for approval, possible narcissistic tendencies).
Children rate their agreement with each item on a scale from 1 (really unlike me) to 4 (really like me). Internal consistencies of the AMPS subscales have been adequate to strong, and Cronbach’s coefficient alphas range from .65 to .86 (Rice & Preusser, 2002; Rice, Kubal, & Preusser, 2004).
Severity of OCD symptoms was measured by the clinician-administered Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS; Goodman, Price, Rasmussen, Riddle, & Rapoport, 1991). The CY-BOCS was administered to the parents and child, either jointly or separately, based on clinical judgment. The CY-BOCS rater was blinded to CAPS-14 and AMPS scores.
The total score of the self-report, 27-item Children’s Depression Inventory (CDI; Kovacs, 1992) was used to assess depressive symptoms. Evidence (Richter, Cox, & Direnfeld, 1994) recommends the inclusion of a measure of depression in non case-control studies of OCD. Statistically significant perfectionism-OCD correlations could become non-significant when accounting for depression scores (Kawamura, Hunt, Frost, & DiBartolo, 2001). Furthermore, perfectionism may have trait-state features (i.e., stable individual differences that vary according to the severity of depressive symptoms) (Cox & Enns, 2003).
Analysis
We did all statistical analyses with SPSS, (v.21). Statistical analysis was performed only for those measures for which Cronbach’s α coefficent was > .7. Because of poor α value for the AMPS contingent self-esteem subscale (α=.58), we excluded this subscale from further analyses.
Possible sex and age effects on the severity of OCD, depressive and perfectionism scores were explored with independent sample t-tests. To test the primary hypothesis, we calculated Pearson’s correlation coefficients as well partial correlation analyses (controlling for age, sex, and depressive symptoms). Then, we performed two hierarchical multiple regression analyses with total CY-BOCS scores as the dependent variable. The first entry included age, sex, and total CDI scores; the second, perfectionism scores (either CAPS-14 or AMPS subscales for the first and second analyses, respectively).
To test the second hypothesis, we performed two hierarchical multiple regression analyses with the total raw CDI score as the dependent variable. The first entry included age, sex, and total CY-BOCS scores; the second, perfectionism scores (either CAPS-14 or AMPS subscales).
Results
Sample characteristics
Participants consisted of 94 youth with OCD (45 boys, 49 girls, age range 9 to 17 y, M = 13.2 y, SD = 2.5 y), of which 20 (21%) also met DSM-IV criteria for social phobia, 11 (12%) for separation or generalized anxiety disorder, 30 (32%) for specific phobia, 25 (27%) had attention-deficit hyperactivity disorder (ADHD), eight (8%) had oppositional defiant disorder, 33 (35%) had a tic disorder, and 17 (18%) had a major depressive disorder.
Measures
Table 1 summarizes descriptive statistics and internal consistency values. Cronbach’s α values for all subscales exceeded .71, with the exception of the AMPS’ contingent self-esteem subscale (α=0.58). Inter-rater Kappa values for K-SADS-P diagnoses of OCD, depressive disorders, and ADHD ranged from .6 to .7 in our sample (85% agreement rate). Score distributions for all measures were not significantly skewed or kurtotic, and Zs ranged from |.066| to |2.00|.
Table 1.
Sample scores descriptives
| Scores | |||
|---|---|---|---|
|
| |||
| Measure | Mean | SD | α |
| Age | 13.2 | 2.5 | N/A |
| CY-BOCS | 22.1 | 5.5 | .74 |
| CAPS-14 SOSP | 10.1 | 3.2 | .71 |
| CAPS-14 SOCP | 10.9 | 5.3 | .78 |
| CAPS-14 SPP | 14.3 | 6.8 | .85 |
| AMPS–Sensitivity | 21.8 | 5.3 | .73 |
| AMPS–Contingent SE | 23.2 | 3.7 | .58 |
| AMPS–Compulsiveness | 14.7 | 4.2 | .73 |
| AMPS–Admiration | 9.3 | 3.8 | .85 |
| CDI | 14.0 | 9.3 | .90 |
N = 94 (age range = 9–17 y).
SD = standard deviation;
α = Cronbach’s coefficient;
p <.05.
Effects of sex on measures
Independent sample t-tests measured differences in age and measurement scores between boys and girls. No significant sex effects were found for CY-BOCS, CAPS-14 or AMPS scores, but girls had significantly higher levels of depressive symptoms than boys (mean scores of 16.1(10.5) and 11.8(7.1), respectively, p = .02).
Correlations between perfectionism and severity of OCD and depressive symptoms
Table 2 depicts Pearson’s correlations between age and the measures in this study. Age was positively and significantly correlated with the severity of depressive (r = .312, p = .02) and OCD (r = .221, p = .03) scores but not perfectionism. Depressive symptoms were positively and significantly (p < .05) correlated with the scores from all CAPS-14 and AMPS subscales, with the exception of the CAPS-14 SOSP scale.
Table 2.
Correlation of OCD, perfectionism, depressive symptoms, and age
| CY-BOCS | CAPS-14 SOSP | CAPS-14 SOCP | CAPS-14 SPP | AMPS–Sensitivity | AMPS–Compulsiveness | AMPS–Admiration | CDI | Age | |
|---|---|---|---|---|---|---|---|---|---|
|
| |||||||||
| r | r | r | r | r | r | r | r | r | |
| p | p | p | p | p | p | p | p | p | |
| CY-BOCS | 1 | .278** | .402** | .332** | .321** | .456** | 0.091 | .572** | .221* |
| .007 | .000 | .001 | .002 | 0 | 0.382 | .000 | .032 | ||
| CAPS-14 SOSP | – | 1 | .547** | .344** | .392** | .467** | .532** | 0.027 | .012 |
| .000 | .001 | .000 | .000 | .000 | 0.797 | .906 | |||
| CAPS-14 SOCP | – | – | 1 | .361** | .569** | .529** | .430** | .431* | .184 |
| .000 | .000 | .000 | .000 | .000 | .077 | ||||
| CAPS-14 SPP | – | – | – | 1 | .494** | .238* | .296** | .382** | .039 |
| .000 | .021 | .004 | .000 | .706 | |||||
| AMPS–Sensitivity | – | – | – | – | 1 | .583** | .491** | .399* | .161 |
| .000 | .000 | .000 | .121 | ||||||
| AMPS–Compulsiveness | – | – | – | – | – | 1 | .340** | .312** | .077 |
| .001 | .002 | .459 | |||||||
| AMPS–Admiration | – | – | – | – | – | – | 1 | .231* | .119 |
| .025 | .253 | ||||||||
| CDI | – | – | – | – | – | – | – | 1 | .312** |
| .002 | |||||||||
| Age | – | – | – | – | – | – | – | – | 1 |
N = 94. r = Pearson’s correlation coefficient;p = significance levels;
p < .05.;
p < .01.
Instruments legend: CY-BOCS = total score, CY-BOCS; CAPS-14 SOSP = CAPS-14, self-oriented perfectionism, striving; CAPS-14 SOCP = CAPS-14, self-oriented perfectionism, critical ; CAPS-14 SPP = CAPS-14, socially prescribed perfectionism; AMPS–Sensitivity = AMPS, sensitivity for mistakes; AMPS–Contingent SE = AMPS, contingent self-esteem; AMPS–Compulsiveness = AMPS, compulsiveness; AMPS–Admiration = AMPS, need for admiration; CDI = Children’s Depression Inventory, total raw score.
OCD severity was positively and significantly (p < .05) associated with all CAPS-14 and AMPS subscale scores, with the exception of the AMPS need-for-admiration subscale. However, controlling for depressive symptoms, age and sex (Table 3), positive and significant correlations (p < .050) were observed for only CAPS-14 SOSP, CAPS-14 SOCP, and AMPS compulsiveness subscales.
Table 3.
Partial Correlation of OCD, perfectionism, and depressive symptoms
| CY-BOCS Total | CAPS-14 SOSP | CAPS-14 SOCP | CAPS-14 SPP | AMPS–Sensitivity | AMPS–Compulsiveness | AMPS–Admiration | |
|---|---|---|---|---|---|---|---|
| r | r | r | r | r | r | r | |
| p | p | p | p | p | p | p | |
| CY-BOCS total | 1 | .330 ** | .209 * | .16 | .123 | .359** | –.061 |
| .001 | .046 | .131 | .247 | 0 | .566 | ||
| CAPS-14 SOSP | – | 1 | .595** | .359** | .416** | .485** | .563** |
| .000 | .000 | .000 | .000 | .000 | |||
| CAPS-14 SOCP | – | – | 1 | .241* | .479** | .462** | .379** |
| .021 | .000 | .000 | .000 | ||||
| AMPS–Sensitivity | – | – | – | – | 1 | .527** | .452** |
| .000 | .000 | ||||||
| AMPS–Compulsiveness | – | – | – | – | – | 1 | .296** |
| .004 | |||||||
| AMPS–Admiration | – | – | – | – | – | – | 1 |
N = 94. r = Partial correlations, controlling for age, sex, and CDI (total raw scores); p = significance levels;
p < .05.
p < .01.
Results of regression analyses
The results of our regression analyses are summarized in Table 4. Regression diagnostics to examine statistical assumptions (examination of residuals and co-linearity diagnostics) did not reveal any concerns. Both CAPS-14 and AMPS scores accounted for significant variation in OCD symptoms (ΔR2 = .074, F(3,90) = 9.88, p = .016, and ΔR2 = .107, F(3,90) = 5.51, p = .002, respectively). CAPS-14 SOSP and the AMPS compulsiveness subscales were positively associated with the severity of OCD symptoms (β = .249, p = .024, and β = .363, p = .000, respectively).
Table 4.
Summary of regression analyses*
| CAPS-14 | AMPS– | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
||||||||||||||
| Dependent variable | Prft measure | Model | df | ΔR2 | Sig | Sex | Age | CDI | CY-BOCS | SOSP | SOCP | SPP | Mis | Comp | Adm |
| B | B | B | B | B | B | B | B | B | B | ||||||
| SE | SE | SE | SE | SE | SE | SE | SE | SE | SE | ||||||
| β | β | β | β | β | β | β | β | β | β | ||||||
| p | p | p | p | p | p | p | p | p | p | ||||||
| CY-BOCS | CAPS-14 subscales | 1. Sex, age, CDI | (3, 90) | .074 | .016 | .89 | .146 | .298 | NA | .424 | .017 | .034 | NA | NA | NA |
| 2. CAPS-14 | .961 | .196 | .064 | .184 | .12 | .079 | |||||||||
| .081 | .067 | .503 | .249 | .017 | .042 | ||||||||||
| .357 | .459 | .000 | .024 | .884 | .667 | ||||||||||
| CY-BOCS | AMPS subscales | 1. Sex, age, CDI | (3, 90) | .107 | .002 | .774 | .173 | .89 | NA | NA | NA | NA | –.019 | .474 | –.217 |
| 2. AMPS | .961 | .189 | .961 | 116 | .13 | .136 | |||||||||
| .071 | .067 | .08 | –.018 | .363 | –.150 | ||||||||||
| .41 | .459 | .363 | .872 | .000 | .114 | ||||||||||
| Total CDI | CAPS-14 | 1. Sex, age, | (3, 90) | .137 | .000 | 2.134 | .636 | NA | .669 | –.956 | .58 | .321 | NA | NA | NA |
| CY-BOCS | |||||||||||||||
| 2. CAPS-14 | 1.428 | .286 | .144 | .264 | .168 | .114 | |||||||||
| .116 | .174 | .397 | –.333 | .329 | .233 | ||||||||||
| .139 | .029 | .000 | .000 | .001 | .006 | ||||||||||
| Total CDI | AMPS | 1. Sex, age, | (3, 90) | .047 | .069 | 2.984 | .712 | .89 | .77 | NA | NA | NA | .399 | –.158 | .134 |
| CY-BOCS | |||||||||||||||
| 2. AMPS | 1.546 | .311 | .961 | .16 | .19 | .235 | .232 | ||||||||
| .162 | .194 | .194 | .457 | .227 | –.072 | .055 | |||||||||
| .057 | .024 | .024 | .000 | .039 | .502 | .564 | |||||||||
N = 94. Model = order of independent variables entered; df: degrees of freedom; ΔR2 = R square change; Sig = significance of change attributed to perfectionism measures;
Unstandardized regression coefficient (B)*, unstandardized standard error (SE)*, ß = standardized partial regression coefficient*; p=significance of ß *; NA = Not applicable. * values were used for each of the predictor variables, rather than for the overall analysis.
CAPS-14, but not AMPS, scores accounted for a significant variance in depressive symptoms (ΔR2 = .346, F(3,90) = 8.43, p = .000, and ΔR2 = .047, F(3,90) = 2.44, p = .069, respectively). The standardized partial regression coefficients revealed that all three CAPS-14 subscales accounted for a significant variance in depressive symptoms. However, the direction of these effects was not uniform: whereas higher SOSP scores were associated with fewer depressive symptoms, higher SOCP and SPP scores were associated with increased severity of depressive symptoms (β = −.397, p = .000; β = .333, p = .000; and β = .233, p = .006; respectively).
Discussion
We studied the association of dimensions of perfectionism with OCD and depressive symptoms in a clinical sample of 94 children and adolescents with OCD. Using two different perfectionism measures, each grounded in a different theoretical framework, we found that perfectionism scores were significantly associated with the severity of OCD symptoms. In addition, CAPS-14, but not AMPS scores were significantly associated with the severity of depressive symptoms. Thus, our findings support the primary and secondary hypotheses of our study.
Both the CAPS-14 SOSP and the AMPS compulsiveness subscales were significantly associated with the severity of OCD symptoms. These two subscales may overlap: SOSP is defined as striving for order or organization and the pursuit of attainable goals. Similarly, compulsiveness is thought to represent “preferences for order, organization, and a deliberate methodological approach to, and concern about, task completion” (Rice & Preusser, 2002). The preference for task completion is similar to reports that patients with OCD are unable to stop performing their rituals (Reed, 1985; Hinds, Woody, Van Ameringen, Schmidt, & Szechtman, 2012).
Although all three CAPS-14 subscales were significantly associated with the severity of depressive symptoms, the direction of the association was not uniform. Two maladaptive dimensions of perfectionism (SOCP and SPP) were positively and significantly associated with the severity of depressive symptoms in our sample. Of note, the association of SOCP and SPP with depression in youth is not unique to OCD (O’Connor, Rasmussen, & Hawton, 2010; Roxborough et al., 2012). For example, SPP and SOCP were associated with depression and anxiety, respectively, among 515 adolescent school-aged children (O’Connor et al., 2010). Indeed, it has been suggested (Egan, Wade, & Shafran, 2010) that maladaptive perfectionism is a trans-diagnostic process, one that is a risk or maintaining factor for eating disorders, anxiety disorders, depression and OCD.
In contrast, SOSP, an adaptive dimension of perfectionism, was associated with fewer depressive symptoms in our study. Interestingly, SOSP was associated with higher OCD symptoms but was associated with less severe depressive symptoms. It is possible that SOSP is a protective factor against depressive, but not OCD symptoms in youth with OCD. Alternatively, worsening depression may result in lower SOSP. Due to the cross sectional design we were unable to determine which of the two interpretations was more accurate. However, given that increased maladaptive perfectionism may adversely affect CBT treatment response in depressed adolescents (Jacobs et al., 2009), the association of depressive symptoms with higher maladaptive and lower adaptive perfectionism may suggest that depressed youth with OCD may present unique clinical challenges.
Our findings differ from those of previous studies (Libby et al., 2004; Ye et al., 2008) that reported that the AMPS sensitivity-to-mistakes subscale was positively and significantly associated with increased severity of depressive and OCD symptoms. This can be accounted for by the larger sample size in our study (N = 94 vs. N = 28 and N = 31) and the use of an adult perfectionism instrument in one of the studies (Libby et al., 2004). In addition, the regression model in the present study differed from the one reported by Ye and colleagues (Ye et al., 2008) by the inclusion of depressive symptoms and the exclusion of the AMPS contingent-self-esteem subscale.
Our findings should be interpreted as preliminary, given the limitations of the study. The current sample size, although much larger than that of previous studies, is still relatively small, which limited our ability to measure effects of factors such as comorbidity and discrete depression and OCD dimensions. In addition, we did not include data on the association of discrete OCD dimensions (e.g. aggression, contamination, symmetry, etc.) due to incomplete information on those aspects. Also, the cross-sectional design of the study is not informative on the temporal sequence of perfectionism and depressive symptoms in youth with OCD. However, the association of depressive symptoms with higher maladaptive and lower adaptive perfectionism could potentially inform clinicians who treat youth with OCD about what to expect when their patients are depressed. Finally, since we did not include a healthy control group or youth with other non-OCD anxiety disorders, the present study does not address the question of whether increased symtpoms of perfectionism are specific to children and adolescents who are diagnosed with OCD. Instead, our findings should be viewed as part of a growing body of literature that suggests that perfectionism is a trans-diagnostic processes.
Conclusions
This was the first study to measure perfectionism in youth with OCD using more than one conceptual framework. We found that symptoms of perfectionism were associated with a variation in the severity of OCD symptoms. In addition, maladaptive and adaptive perfectionism were associated with an increase and decrease in depressive symptoms, respectively. To better understand dimensions of dysfunction and reslinience in children and adolescents with OCD, future studies should include larger sample sizes, employ a longitudinal design and compare OCD with other diagnostic groups.
Acknowledgments/Conflicts of Interest
This study was supported by an operating grant from the Ontario Mental Health Foundation (NS). This study was prepared with the editorial assistance of Sharon Nancekivell, medical editor, Guelph, Ontario.
References
- Baptista MN, Magna LA, McKay D, Del-Porto JA. Assessment of obsessive beliefs: Comparing individuals with obsessive-compulsive disorder to a medical sample. Journal of Behavior Therapy and Experimental Psychiatry. 2011;42(1):1–5. doi: 10.1016/j.jbtep.2010.08.002. [DOI] [PubMed] [Google Scholar]
- Blatt SJ, Zuroff DC, Bondi CM, Sanislow CA, 3rd, Pilkonis PA. When and how perfectionism impedes the brief treatment of depression: Further analyses of the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology. 1998;66(2):423–428. doi: 10.1037//0022-006x.66.2.423. [DOI] [PubMed] [Google Scholar]
- Boergers J, Spirito A, Donaldson D. Reasons for adolescent suicide attempts: Associations with psychological functioning. Journal of the American Academy of Child and Adolescent Psychiatry. 1998;37(12):1287–1293. doi: 10.1097/00004583-199812000-00012. [DOI] [PubMed] [Google Scholar]
- Cox BJ, Enns MW. Relative stability of dimensions of perfectionism in depression. Canadian Journal of Behavioural Science. 2003;35(2):124–132. [Google Scholar]
- Dunkley DM, Blankstein KR, Masheb RM, Grilo CM. Personal standards and evaluative concerns dimensions of “clinical” perfectionism: A reply to Shafran et al. (2002, 2003) and Hewitt et al (2003) Behaviour Research and Therapy. 2006;44(1):63–84. doi: 10.1016/j.brat.2004.12.004. [DOI] [PubMed] [Google Scholar]
- Egan SJ, Wade TD, Shafran R. Perfectionism as a transdiagnostic process: A clinical review. Clinical Psychology Review. 2010;31(2):203–212. doi: 10.1016/j.cpr.2010.04.009. [DOI] [PubMed] [Google Scholar]
- Flett GL, Hewitt PL, Boucher DJ, Davidson LA, Munro Y. The child–adolescent perfectionism scale: Development, validation, and association with adjustment. 1997. Unpublished manuscript.
- Frost RO, Marten P, Lahart C, Rosenblate R. The dimensions of perfectionism. Cognitive Therapy and Research. 1990;14(5):449–468. [Google Scholar]
- Geller D, Biederman J, Faraone SV, Frazier J, Coffey BJ, Kim G, Bellordre CA. Clinical correlates of obsessive compulsive disorder in children and adolescents referred to specialized and non-specialized clinical settings. Depress Anxiety. 2000;11(4):163–168. doi: 10.1002/1520-6394(2000)11:4<163::AID-DA3>3.0.CO;2-3. [DOI] [PubMed] [Google Scholar]
- Goodman WK, Price LH, Rasmussen SA, Riddle MA, Rapoport JL. Children’s yale-brown obsessive compulsive scale (CY-BOCS) Providence, RI: Department of Psychiatry Brown University School of Medicine; 1991. [Google Scholar]
- Hewitt PL, Flett GL, Turnbull Donovan W, Mikail SF. The Multidimensional Perfectionism Scale: Reliability, validity, and psychometric properties in psychiatric samples. Psychological Assessment: A Journal of Consulting and Clinical Psychology. 1991;3(3):464–468. [Google Scholar]
- Hinds AL, Woody EZ, Van Ameringen M, Schmidt LA, Szechtman H. When too much is not enough: Obsessive-compulsive disorder as a pathology of stopping, rather than starting. PloS One. 2012;7(1):e30586. doi: 10.1371/journal.pone.0030586. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Jacobs RH, Silva SG, Reinecke MA, Curry JF, Ginsburg GS, Kratochvil CJ, March JS. Dysfunctional attitudes scale perfectionism: A predictor and partial mediator of acute treatment outcome among clinically depressed adolescents. Journal of Clinical Child and Adolescent Psychology: The Official Journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53. 2009;38(6):803–813. doi: 10.1080/15374410903259031. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Kaufman J, Birmaher B, Brent D, Rao U, Flynn C, Moreci P, Ryan N. Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL): Initial reliability and validity data. Journal of the American Academy of Child and Adolescent Psychiatry. 1997;36(7):980–988. doi: 10.1097/00004583-199707000-00021. [DOI] [PubMed] [Google Scholar]
- Kawamura KY, Hunt SL, Frost RO, DiBartolo PM. Perfectionism, anxiety, and depression: Are the relationships independent? Cognitive Therapy and Research. 2001;25(3):291–301. [Google Scholar]
- Kovacs M. The Children’s Depression Inventory. 1992. Unpublished manuscript.
- Libby S, Reynolds S, Derisley J, Clark S. Cognitive appraisals in young people with obsessive-compulsive disorder. Journal of Child Psychology and Psychiatry, and Allied Disciplines. 2004;45(6):1076–1084. doi: 10.1111/j.1469-7610.2004.t01-1-00300.x. [DOI] [PubMed] [Google Scholar]
- McCreary BT, Joiner TE, Schmidt NB, Ialongo NS. The structure and correlates of perfectionism in African American children. Journal of Clinical Child and Adolescent Psychology. 2004;33(2):313–324. doi: 10.1207/s15374424jccp3302_13. [DOI] [PubMed] [Google Scholar]
- O’Connor RC, Dixon D, Rasmussen S. The structure and temporal stability of the Child and Adolescent Perfectionism Scale. Psychological Assessment. 2009;21(3):437–443. doi: 10.1037/a0016264. [DOI] [PubMed] [Google Scholar]
- O’Connor RC, Rasmussen S, Hawton K. Predicting depression, anxiety and self-harm in adolescents: The role of perfectionism and acute life stress. Behaviour Research and Therapy. 2010;48(1):52–59. doi: 10.1016/j.brat.2009.09.008. [DOI] [PubMed] [Google Scholar]
- Pediatric OCD Treatment Study (POTS) Team. Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: The pediatric OCD treatment study (POTS) randomized controlled trial. JAMA: The Journal of the American Medical Association. 2004;292(16):1969–1976. doi: 10.1001/jama.292.16.1969. [DOI] [PubMed] [Google Scholar]
- Reed GF. Obsessional Experience and Compulsive Behaviour: A Cognitive-Structural Approach. Orlando, FL: Academic Press, University of Michigan; 1985. [Google Scholar]
- Rice KG, Kubal AE, Preusser KJ. Perfectionism and Children’s Self-Concept: Further Validation of the Adaptive/Maladaptive Perfectionism Scale. Psychology in the Schools. 2004;41(3):279–290. [Google Scholar]
- Rice KG, Preusser KJ. The Adaptive/Maladaptive Perfectionism Scale. Measurement and Evaluation in Counseling and Development. 2002;34(4):210–222. [Google Scholar]
- Richter MA, Cox BJ, Direnfeld DM. A comparison of three assessment instruments for obsessive-compulsive symptoms. Journal of Behavior Therapy and Experimental Psychiatry. 1994;25(2):143–147. doi: 10.1016/0005-7916(94)90007-8. [DOI] [PubMed] [Google Scholar]
- Roxborough HM, Hewitt PL, Kaldas J, Flett GL, Caelian CM, Sherry S, Sherry DL. Perfectionistic self-presentation, socially prescribed perfectionism, and suicide in youth: A test of the perfectionism social disconnection model. Suicide & Life-Threatening Behavior. 2012;42(2):217–233. doi: 10.1111/j.1943-278X.2012.00084.x. [DOI] [PubMed] [Google Scholar]
- Taylor S, McKay D, Abramowitz JS. Hierarchical structure of dysfunctional beliefs in obsessive-compulsive disorder. Cognitive Behaviour Therapy. 2005;34(4):216–228. doi: 10.1080/16506070510041167. [DOI] [PubMed] [Google Scholar]
- Valderhaug R, Ivarsson T. Functional impairment in clinical samples of Norwegian and Swedish children and adolescents with obsessive-compulsive disorder. European Child & Adolescent Psychiatry. 2005;14(3):164–173. doi: 10.1007/s00787-005-0456-9. [DOI] [PubMed] [Google Scholar]
- Ye HJ, Rice KG, Storch EA. Perfectionism and peer relations among children with obsessive-compulsive disorder. Child Psychiatry and Human Development. 2008;39(4):415–426. doi: 10.1007/s10578-008-0098-5. [DOI] [PubMed] [Google Scholar]