Perfectionism Dimensions and Dependency in Relation to Personality ...

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Nov 11, 2011 - that self-criticism was primarily related to personality vulnerability (aggression/anger/hostility, Type D negative affectivity) and psychosocial ...
J Clin Psychol Med Settings (2012) 19:211–223 DOI 10.1007/s10880-011-9271-2

Perfectionism Dimensions and Dependency in Relation to Personality Vulnerability and Psychosocial Adjustment in Patients with Coronary Artery Disease David M. Dunkley • Deborah Schwartzman • Karl J. Looper • John J. Sigal • Andrena Pierre Mark A. Kotowycz



Published online: 11 November 2011 Ó Springer Science+Business Media, LLC 2011

Abstract The present study sought to illuminate selfcriticism and personal standards dimensions of perfectionism and dependency as specific cognitive-personality vulnerability factors that might contribute to a better understanding of numerous psychosocial problem areas that are relevant to coronary artery disease (CAD). One hundred and twenty-three patients diagnosed with clinically significant CAD completed self-report questionnaires. Zero-order correlations and factor analysis results revealed that self-criticism was primarily related to personality vulnerability (aggression/anger/hostility, Type D negative affectivity) and psychosocial maladjustment (depressive symptoms, worry, avoidant coping, support dissatisfaction), whereas personal standards was primarily related to adaptive coping (problem-focused coping, positive D. M. Dunkley (&)  D. Schwartzman  K. J. Looper  J. J. Sigal  A. Pierre Department of Psychiatry, Institute of Community and Family Psychiatry, Lady Davis Institute, SMBD Jewish General Hospital, 4333 Coˆte Ste-Catherine Road, Montreal, QC H3T 1E4, Canada e-mail: [email protected] D. M. Dunkley  K. J. Looper  J. J. Sigal  A. Pierre Department of Psychiatry, McGill University, Montreal, QC, Canada D. M. Dunkley  D. Schwartzman Department of Psychology, McGill University, Montreal, QC, Canada M. A. Kotowycz Division of Cardiology, SMBD Jewish General Hospital, Montreal, QC, Canada M. A. Kotowycz Department of Cardiology, McGill University, Montreal, QC, Canada

reinterpretation) and dependency was primarily related to worry. Hierarchical regression results demonstrated the incremental utility of self-criticism, personal standards, and dependency in relation to (mal)adjustment over and above aggression/anger/hostility, negative affectivity, and social inhibition. Continued efforts to understand the role of perfectionism dimensions and dependency in CAD appear warranted. Keywords Perfectionism  Dependency  Personality  Psychosocial adjustment  Coronary artery disease

Introduction The literature on personality variables that play a role in coronary artery disease (CAD) has mostly focused on the Type A behaviour pattern and, more recently, the Type D, ‘distressed’ personality (see Razzini et al., 2008). While meta-analyses have concluded that there is no evidence that the Type A behaviour pattern (e.g., Friedman & Rosenman, 1959) predicts coronary heart disease, research has found a clear effect of the hostility component of Type A on a variety of cardiovascular outcomes (e.g., Chida & Steptoe, 2009; Rozanski, Blumenthal, & Kaplan, 1999). The Type D personality (e.g., Denollet, Sys, & Brutsaert, 1995), which refers to individuals characterized by negative affectivity (i.e., the tendency to experience negative emotions) and social inhibition (i.e., the tendency to inhibit these emotions by avoiding social contacts), has been identified as a negative prognostic factor in CAD patients (see Razzini et al., 2008). Further, several reviews have suggested that negative affectivity might have much predictive value regarding the clustering of risk factors and the early identification of patients who are inclined to

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experience various manifestations of psychosocial stress over time, which, in turn, substantially elevates the risk of cardiac events (e.g., Rozanski et al., 1999; Smith & MacKenzie, 2006; Suls & Bunde, 2005). Personality vulnerability variables refer to individual differences in characteristic ways of thinking, feeling, behaving, and relating to others that can contribute to the generation of stress and a wide variety of psychosocial problems. The literature that deals with perfectionism and dependency as specific cognitive-personality vulnerability traits suggests a potentially fruitful approach that may provide unique information to more fully account for personal variations in outcomes in CAD above and beyond hostility and negative affectivity. Over the past two decades, numerous investigators have distinguished between a perfectionism dimension that has adaptive aspects and a perfectionism dimension that is primarily maladaptive (see Dunkley, Blankstein, Masheb, & Grilo, 2006a; Stoeber & Otto, 2006). We refer to these two dimensions as personal standards and self-criticism. Personal standards involves the setting of and striving for high standards and goals for oneself, and has an inconsistent association with maladjustment (see Dunkley et al., 2006a; Stoeber & Otto, 2006). On the other hand, self-criticism closely resembles Blatt’s (1974, 2004) self-criticism construct in that it involves constant and harsh self-scrutiny, overly critical evaluations of one’s own behavior, and chronic concerns about others’ criticism (Dunkley, Zuroff, & Blankstein, 2003). Selfcriticism can also be distinguished from Blatt’s (1974, 2004) dependency construct, which involves chronic concerns with interpersonal relationships, feelings of loneliness and helplessness, and fears of abandonment and rejection. Although there are many different measures of perfectionism (e.g., Frost, Marten, Lahart, & Rosenblate, 1990; Hewitt & Flett, 1991), studies have indicated considerable redundancy among these measures in predicting maladjustment (e.g., Dunkley et al., 2006a; Dunkley, Zuroff, & Blankstein, 2006b). Further, factor analytic studies have demonstrated self-criticism to be the primary indicator of the self-critical perfectionism dimension (e.g., Dunkley & Blankstein, 2000; Dunkley et al., 2003), and self-criticism has been found to account for the effects of various perfectionism measures across a wide range of psychosocial maladjustment outcomes, including daily stress, avoidant coping, negative perceptions of social support, anxious symptoms, and depressive symptoms (Dunkley et al., 2006a, b). In addition, the effects of self-criticism on maladjustment have been found to be more pernicious and pervasive than the effects of dependency (see Zuroff, Mongrain, & Santor, 2004a for a review). Self-criticism could be potentially important in the context of CAD because of its hypothesized association with numerous

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previously established predictors of outcome in CAD, namely aggression/anger/hostility, negative affectivity, depressive symptoms, worry, avoidant coping, and support dissatisfaction. Regarding aggression/anger/hostility, self-critical individuals have been described as competitive and hostile towards others, and having difficulty controlling their anger. They express their anger towards others, but also towards the self in the form of harsh self-criticism (Blatt, 2004; Blatt, Cornell, & Eshkol, 1993). Indeed, self-criticism has been related to higher levels of trait anger, anger directed towards the self, and anger directed towards others, and lower levels of control over anger (Dunkley, Blankstein, & Flett, 1995; Smith, McGonigle, & Benjamin, 1998; Vliegen & Luyten, 2008). Further, self-criticism/ perfectionism and dependency have been described as distinct neurotic styles (see Blatt, 2004), and studies have consistently demonstrated a strong relation between selfcriticism and negative affectivity (see Dunkley et al., 2006a) and a moderate relation between dependency and negative affectivity (see Zuroff et al., 2004a). Beyond a tendency to experience aggression/anger/ hostility and negative affectivity, considerable support has been accrued for a strong direct link between self-criticism and depression-related phenomenology (Blatt, 2004; Zuroff et al., 2004a). Indeed, in a sample of CAD patients, Stafford, Jackson, and Berk (2009) found that the selfcriticism/perfectionism subscale of autonomy was the best predictor of depressive symptoms. The vulnerability of individuals with higher self-criticism to experience depressive symptoms is pertinent to CAD because a growing body of research has established depression as a significant predictor of negative outcomes of CAD, such as health-related quality of life and cardiac mortality (e.g., Frasure-Smith & Lesperance, 2006; Ruo et al., 2003). In addition, individuals with higher self-criticism and individuals with higher personal standards are prone to experience worry by engaging in stringent self-evaluations and focusing on the negative aspects of events such that even ordinary events can be interpreted as threatening stressors (Dunkley Blankstein, Halsall, Williams, & Winkworth, 2000; Dunkley et al., 2003; Sto¨ber, 1998). On the other hand, individuals with higher dependency are prone to experience worry concerning abandonment, rejection, and loss (Blatt et al., 1993; Dunkley, Blankstein, & Flett, 1997). Everyday worries might contribute to increased risk for negative CAD outcomes as stress from home, work, or financial issues have been found to significantly increase risk for myocardial infarct (Kubzansky et al., 1997; Rosengren et al., 2004). Although both individuals with higher self-criticism and individuals with higher personal standards may be prone to experience worry, individuals with higher personal

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standards typically respond to daily stressors as a challenge and, as a result, tend to engage in adaptive forms of coping, such as problem-focused coping (e.g., Dunkley & Blankstein, 2000; Dunkley et al., 2000; see Dunkley et al., 2006a). Individuals with higher self-criticism, on the other hand, perceive stressful situations as threatening, become preoccupied with their perceived deficiencies, and consequently typically respond with avoidant coping (Dunkley et al., 2000, 2003). Avoidant coping is another characteristic associated with self-criticism that might result in harmful cardiovascular changes in CAD patients over time because this threat-like response results in decreased cardiac performance in the form of inhibited vascular dilation or vasoconstriction (Blascovich & Tomaka, 1996). Finally, because individuals with higher self-criticism perceive that mistakes and shortcomings will result in rejection from others, these individuals perceive that others are unavailable to help them in times of stress (Dunkley et al., 2000, 2003). The dissatisfaction with social support of individuals with higher self-criticism is another matter of concern because impaired social support is among the most robust predictors of outcomes in CAD patients (see Kuper, Marmot, & Hemingway, 2002; Lett et al., 2005). The main purpose of the present study was to illuminate self-criticism and personal standards dimensions of perfectionism and dependency as specific cognitive-personality vulnerability factors that might contribute to a better understanding of numerous psychosocial problem areas that are relevant to CAD. Although associations of perfectionism dimensions and dependency with various indices of psychosocial adjustment have been found in student, community, and psychiatric populations, little research has studied perfectionism and dependency in CAD patients. In order to establish the applicability of these prior findings to understanding CAD, these relations need to be tested in CAD patients. The present study is the first to examine the associations of perfectionism dimensions and dependency with psychosocial adjustment in CAD patients. We hypothesized that self-criticism would exhibit moderate to strong correlations with previously established personality vulnerability variables in CAD (aggression/anger/hostility, negative affectivity, social inhibition) and various maladaptive psychosocial outcomes, including depressive symptoms, worry, avoidant coping, and support dissatisfaction. On the other hand, we hypothesized that personal standards would correlate with various adaptive (problem-focused coping, positive reinterpretation) and maladaptive (worry) psychosocial outcomes. We hypothesized that dependency would correlate, albeit to a weaker extent than self-criticism, with negative affectivity, depressive symptoms, and worry. Finally, in order to establish self-criticism, personal standards, and dependency as specific cognitive-personality dimensions that add unique explanatory power to the

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understanding of various problem areas in CAD, it is important to distinguish these specific dimensions from previously established personality vulnerability variables in CAD (see Smith & MacKenzie, 2006; Suls & Bunde, 2005). Some reviewers have proposed that the effects of specific cognitive-personality variables, such as perfectionism and dependency, might be explained through shared variance with a single, broad personality variable such as negative affectivity (e.g., Coyne & Whiffen, 1995). This is a plausible competing hypothesis given that negative affectivity is conceptualized to subsume all of the negative emotions, especially depression, anxiety, and anger (see Suls & Bunde, 2005). Some research has distinguished self-criticism and dependency from negative affectivity in terms of unique relations with depressive symptoms and interpersonal characteristics (see Zuroff et al., 2004a for a review). However, to our knowledge, no studies have examined whether perfectionism dimensions and dependency have unique associations with aggression/ anger/hostility or worry controlling for negative affectivity. Thus, we examined the incremental utility of perfectionism dimensions and dependency in relation to several personality vulnerability and psychosocial outcomes over and above aggression/anger/hostility, negative emotionality, and social inhibition. If perfectionism dimensions and dependency uniquely account for elevations in several established predictors of outcome in CAD, this might help better identify patients who experience numerous indicators of psychosocial stress and, hence, are potentially at increased risk for cardiovascular events.

Method Participants Participants were a subset of 193 patients who underwent coronary angiography at the Sir Mortimer B. Davis— Jewish General Hospital. From June 2005 to October 2007, patients who were scheduled for elective cardiac catheterization were approached to participate in the study. The inclusion criteria for the study were age (18 years or older), ability to communicate in English or French, and ability to provide written informed consent. Clinically significant CAD was said to be present in any patient with 50% or greater narrowing of one or more of the major coronary arteries, since it has been shown that this leads to a significant reduction in flow (Rafflenbeul, Urthaler, Lichtlen, & James, 1980). Based on the results of the angiogram, sixty-four percent (n = 123) of the patients were classified with clinically significant CAD, 16% (n = 30) with nonsignificant CAD, and 21% (n = 40) with normal arterial functioning. For the purpose of this study, the sample

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consisted of the 123 patients (93 men, 30 women) with a mean age of 66.38 (SD = 9.72) diagnosed with clinically significant CAD. Fifteen percent (n = 18) of the patients were diagnosed with pulmonary hypertension, 37% (n = 46) of the participants suffered from arthritis or rheumatism, 29% (n = 36) from diabetes, 48% (n = 59) from hypertension, 24% (n = 30) from joint problems, and 23% (n = 28) from hearing problems. Fifty-nine percent (n = 73) of the participants completed the questionnaires in English and 41% (n = 50) completed the French version of the questionnaires. Participants were compensated $20 for their participation. Procedure Participants participated voluntarily after a human investigation committee approved the study and informed consent was obtained. Several weeks (mean 20 days, SD = 17) prior to their cardiac catheterization, participants completed self-report questionnaires, including measures of personality vulnerability, depressive symptoms, worry, coping, support dissatisfaction, and physical functioning. Given a bilingual population, measures for which a French translation was not available were translated from English to French using careful forward and back translation techniques, including the measures of personal standards, aggression/anger/hostility, Type D personality, worry, and coping. Measures

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Boucher et al., 2006). Although the MDEQ is one of several shortened versions of the original DEQ (Blatt, D’Afflitti, & Quinlan, 1976), Zuroff, Mongrain, and Santor (2004b) concluded from their review that the MDEQ is a more valid measure of Blatt’s (1974, 2004) self-criticism and dependency constructs because the other shortened scales primarily sample the affective referents of the constructs, whereas the MDEQ scales better assess the interpersonal and motivational aspects of self-criticism and dependency and are more distinct from one another. Coefficient alphas in the present study for MDEQ selfcriticism (.78, .80) and dependency (.69, .74) were comparable for the English- and French-speaking participants, respectively. Personal Standards Seven items from the Frost Multidimensional Perfectionism Scale (FMPS; Frost et al., 1990) were used to assess personal standards (e.g., ‘‘I set higher goals than most people,’’ ‘‘If I do not set the highest standards for myself, I am likely to end up a second-rate person’’). Response choices ranged from 1 (strongly disagree) to 5 (strongly agree). Scores can vary from 7 to 49, with high scores indicating the setting of and striving for high personal standards of performance. The personal standards scale has well-established reliability and construct validity (Frost et al., 1990). Coefficient alphas in the present study for personal standards were comparable for the Englishspeaking (.78) and French-speaking (.88) participants.

Self-Criticism and Dependency Aggression/Anger/Hostility The 48-item McGill Revision of the Depressive Experiences Questionnaire (MDEQ; Santor, Zuroff, & Fielding, 1997) was used to assess self-criticism (30 items; e.g., ‘‘I often find that I don’t live up to my own standards and ideals,’’ ‘‘There is a considerable difference between how I am now and how I would like to be’’) and dependency (30 items; e.g., ‘‘After an argument, I feel very lonely,’’ ‘‘I often think about the danger of losing someone who is close to me’’). Response choices ranged from 1 (strongly disagreed) to 7 (strongly agreed). Scores can vary from 30 to 210 for self-criticism and dependency, with high scores indicating higher frequency and intensity with which individuals display the attributes associated with Blatt’s (1974, 2004) prototypical self-critical and dependent individuals. Boucher, Cyr, and Fortin’s (2006) French translation of the MDEQ was administered to French-speaking participants. The MDEQ self-criticism and dependency scales have demonstrated good convergent and discriminant validity (Santor, Zuroff, Mongrain, & Fielding, 1997;

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Aggression/anger/hostility was measured using Buss and Warren’s (2000) 15-item Aggression Questionnaire (AQ) Short Form. The AQ assesses physical aggression (e.g., ‘‘I may hit someone if he or she provokes me’’), verbal aggression (e.g., ‘‘My friends say that I argue a lot’’), anger (e.g., ‘‘At times I get very angry for no good reason’’), hostility (e.g., ‘‘Other people always seem to get the breaks’’), and indirect aggression (e.g., ‘‘If I’m angry enough, I may mess up someone’s work’’). Response choices ranged from 1 (not at all like me) to 5 (completely like me). Scores can vary from 15 to 75, with high scores indicating a stronger tendency to experience aggression, anger, and hostility. The AQ has demonstrated acceptable internal consistency, and convergent and discriminant validity (Buss & Warren, 2000). Coefficient alphas in the present study for aggression/anger/hostility were comparable for the English-speaking (.81) and French-speaking (.85) participants.

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Type D Personality: Negative Affectivity and Social Inhibition The 16-item Type D Scale (DS; Denollet, 1998) was used to assess the negative affectivity (8 items; e.g., ‘‘I take a gloomy view of things,’’ ‘‘I am often in a bad mood’’) and social inhibition (8 items; e.g., ‘‘I find it hard to express my opinions to others,’’ ‘‘I have little impact on other people’’) dimensions of the Type D personality. Participants rated their personality on a 5-point Likert scale ranging from 0 (false) to 4 (true). Scores can vary from 0 to 32 for both scales, with high negative affectivity scores indicating a stronger tendency to experience negative emotions across time and situations and high social inhibition scores indicating a stable tendency to inhibit the expression of emotions and behaviors in social interactions. Type D personality was considered to be present in 37% (n = 45) of the patients, according to established cutoff scores of 10 or greater on each of the negative affectivity and social inhibition scales. The negative affectivity and social inhibition scales have demonstrated adequate internal consistency and construct validity (Denollet, 1998). Coefficient alphas in the present study for Type D negative affectivity (.89, .81) and social inhibition (.67, .76) were comparable for the English- and French-speaking participants, respectively. Depressive Symptoms The Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) consists of 21 items that refer to symptoms of depression in the previous week. Participants rated items along a continuum from 0 if the symptom was not present to 3 if the depressive symptom was experienced to an extreme degree. Higher scores indicated a more severe level of depressive symptoms. Bourque and Beaudette’s (1982) French translation was administered to French-speaking participants. The validity and internal consistency of the BDI has been established across samples (Beck, Steer, & Garbin, 1988; Bourque & Beaudette, 1982). Coefficient alphas in the present study for depressive symptoms were comparable for the Englishspeaking (.85) and French-speaking (.84) participants. Worry Worry was assessed using 29 items derived from a list of worries found in Tallis, Eysenck, and Mathews’ (1992) survey of a general adult population, and a questionnaire used by Kubzansky et al. (1997) that examined worry as a predictor of CAD. The questionnaire measures six categories of worry: relationships (7 items; e.g., ‘‘not having anyone to help me when I need help’’), money-related (4

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items; e.g., ‘‘that I can’t pay my bills’’), health-related (5 items; e.g., ‘‘that I will become very ill or incapacitated’’), work-related (6 items; e.g., ‘‘problems with co-workers’’), socio-political (3 items; e.g., ‘‘not having social services when I need them because of governmental policies’’), and personal image (4 items; e.g., ‘‘my weight’’). Response choices ranged from 1 (never) to 9 (always). Coefficient alphas in the present study for worry were comparable for the English-speaking (.91) and French-speaking (.77) participants. Coping Participants completed selected 4-item scales from the dispositional version of the COPE Inventory (Carver, Scheier, & Weintraub, 1989). Consistent with previous factor analytic findings (Carver et al., 1989; Dunkley et al., 2000), avoidant coping was measured by the denial (e.g., ‘‘I say to myself ‘‘this isn’t real’’’’), behavioural disengagement (‘‘I reduce the amount of effort I put into solving the problem’’), and mental disengagement (e.g., ‘‘I turn to work or other substitute activites to take my mind off things’’) scales. Problem-focused coping was measured using the planning (e.g., ‘‘I make a plan of action to fix the problem’’) and active coping (e.g., ‘‘I concentrate my efforts on doing something about it’’) scales. The positive reinterpretation and growth scale (e.g., ‘‘I look for something good in what is happening’’) of the COPE assessed a separate coping category (Carver et al., 1989). Participants rated each item from 1 (never) to 9 (always) on the degree to which they use each coping strategy. Scores can vary from 12 to 108 for avoidant coping, with high scores indicating a greater tendency to deny the reality of stressful events, reduce one’s effort to deal with stressors, and use alternative activities to take one’s mind off a problem. Scores can range from 8 to 72 for problem-focused coping, with high scores indicating a stronger tendency to think about how to cope with stressors and take active steps to try to remove or circumvent stressors. Scores can range from 4 to 36 for positive reinterpretation, with high scores indicating a greater tendency to construe stressful transactions in positive terms. The COPE scales have demonstrated moderate internal consistency and convergent and discriminant validity (Carver et al., 1989). Coefficient alphas in the present study for avoidant coping (.75, .59), problem-focused coping (.88, .81), and positive reinterpretation (.51, .66) were comparable for the English- and Frenchspeaking participants, respectively. Support Dissatisfaction Four items from Sherbourne and Stewart’s (1991) Social Support Survey (SSS) were selected to assess social

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dissatisfaction. Participants rated four questions (‘‘How would you describe your social life?’’, ‘‘In general, are you satisfied with your relationships with your friends?’’, ‘‘How do you find your relationship with your children?’’, ‘‘How do you feel about the relationship with the person you regard as your spouse or partner?’’) along a 4-point continuum ranging from ‘‘very satisfactory’’ to ‘‘very unsatisfactory’’. Scores can vary from 4 to 16, with high scores indicating greater dissatisfaction with interpersonal relationships. The validity and internal consistency of the Social Support Survey has been well-established (Anderson, Bilodeau, Deshaies, Gilbert, & Jobin, 2005; Sherbourne & Stewart, 1991). Coefficient alphas in the present study for support dissatisfaction were comparable for the English-speaking (.67) and French-speaking (.55) participants.

between men and women, and between participants who completed the English questionnaires and those who completed the French questionnaires. Out of a total of 78 comparisons between correlates for men and women, there were three significant (p \ .05) differences. Out of a total of 78 comparisons between correlates for English and French participants, there were nine significant (p \ .05) differences. Thus, because the number of significant differences approximated the number that could be expected by chance, the results were considered to be comparable between men and women, and between participants completing either the English or French version of the questionnaires.

Physical Functioning

Zero-order correlations were used to examine the relation between self-criticism, personal standards, and dependency, and the indices of personality vulnerability and psychosocial adjustment. As Table 1 indicates, self-criticism, personal standards, and dependency showed different correlations with various indices of personality vulnerability and psychosocial adjustment. Self-criticism showed moderate to strong correlations (r = .36 to .61) with other personality vulnerability measures (aggression/anger/ hostility, Type D negative affectivity) and various indices of psychosocial maladjustment (depressive symptoms, worry, avoidant coping, support dissatisfaction). In order to further differentiate self-criticism from depressive symptoms, given their strong correlation (see Zuroff et al., 2004a), partial correlations were computed to assess how self-criticism related to the indices of personality vulnerability and psychosocial adjustment partialling out the shared variance between self-criticism and depressive symptoms. Results indicated that self-criticism was still related to aggression/anger/hostility (pr = .39, p \ .001), Type D negative affectivity (pr = .44, p \ .001), worry (pr = .31, p \ .001), avoidant coping (pr = .20, p \ .05), and support dissatisfaction (pr = .30, p \ .001), controlling for depressive symptoms. On the other hand, personal standards showed small to moderate correlations (r = .19 to .30) with psychosocial adjustment (problem-focused coping, positive reinterpretation) and maladjustment (worry). Dependency exhibited weak to moderate correlations (r = .18 to .42) with Type D negative affectivity, Type D social inhibition, depressive symptoms, and worry. Finally, whereas aggression/anger/hostility, Type D negative affectivity, and Type D social inhibition were all associated with depressive symptoms, worry, avoidant coping, and support dissatisfaction, only the Type D dimensions were associated with lower adaptive coping (problem-focused coping, positive reinterpretation).

Physical functioning was assessed using a sub-component of 10 items from the Medical Outcomes Study 36-item Short Form Health Survey (SF-36; Ware & Sherbourne, 1992). The SF-36 physical functioning scale assesses the ability to perform everyday physical activities. Participants were instructed to read a list of vigorous and moderate activities and rate whether they experienced limitations resulting from health problems ‘‘a lot,’’ ‘‘a little,’’ or ‘‘not at all.’’ Scores can vary from 0 to 100, with high scores indicating greater perceived capability in physical activities. Leple`ge, Ecosse, Verdier, and Perneger’s (1998) French translation of the SF-36 was administered to French-speaking participants. The validity and internal consistency of the SF-36 have been well-established (Haley, McHorney, & Ware, 1994; Leple`ge et al., 1998). Coefficient alphas in the present study for physical functioning were comparable for the English-speaking (.88) and French-speaking (.94) participants.

Results The means, standard deviations, alpha coefficients, and intercorrelations among self-criticism, personal standards, dependency, aggression/anger/hostility, Type D negative affectivity, Type D social inhibition, depressive symptoms, worry, coping, support dissatisfaction, and physical functioning measures are reported in Table 1. The alpha coefficients of the measures were computed for the combined sample of 123 English- and French-speaking participants, and are presented in bold on the diagonal. As suggested by Cohen, Cohen, West, and Aiken (2003), z-tests that utilize Fisher’s r to z transformations were used to examine differences in the intercorrelations

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Zero-Order Correlations

.14

.83 .12

6.44

21.54

.11

.01

.24**

.30***

.10

.19*

.06

-.11

-.02

2

-.15

.04

.10

.01

.06

.42***

.27**

.18*

.19*

.00

.71

18.85

127.47

3

.23*

.06

.07

.32***

.20*

.33***

.13

.43***

.83

9.19

27.17

-.10

4

.29**

.61***

.56***

.38***

.86

6.29

10.03

-.10

.56***

-.27**

-.25**

5

.25**

.22*

.29**

.72

5.43

12.17

-.19*

.24**

-.24**

-.33***

6

.35***

.50***

.85

7.33

9.36

-.38***

.41***

-.08

-.13

7

-.08

.41***

.01

-.11

.27**

.87

32.53

100.49

8

.70

10.31

36.00

-.17

.23*

.17

-.10

9

11.29

38.54

.09

-.03

.63***

.85

10

5.55

18.26

-.02

-.08

.57

11

2.17

6.58

.02

.61

12

26.60

57.94

.91

13

* p \ .05; ** p \ .01; *** p \ .001

N = 123

Alphas are presented in bold on the diagonal

Aggr./Anger/Hostil. Aggression/anger/hostility; Neg. Affect. Negative affectivity; Soc. Inhibit. Social inhibition; Sx. Symptoms; Prob-Foc. Problem-focused; Reinterpret. Reinterpretation; Dissatis. Dissatisfaction; Function. Functioning

22.40

SD

-.14

.46***

-.05

-.08

.36***

.50***

.57***

.19*

.61***

.47***

.23* .01

.78

109.00

1

M

Physical Function.

Avoidant coping

9.

13.

Worry

8.

Support Dissatis.

Depressive Sx.

7.

12.

Type D Soc. Inhibit.

6.

Prob-Foc. coping

Type D Neg. Affect.

5.

Positive Reinterpret.

Aggr./Anger/Hostil.

4.

10.

Personal standards Dependency

2. 3.

11.

Self-criticism

1.

Variables

Table 1 Means, standard deviations, alpha coefficients, and intercorrelations

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Factor Analysis In order to identify common factors that underlie the interrelations among the measures, principal axis factor analysis with oblique rotation of the 13 measures identified four distinct factors. Visual examination of the scree plot as well as exploration of three and five-factor solutions indicated that a four-factor solution provided the most parsimonious and informative fit. Eigenvalues for this solution were 3.94, 2.04, 1.29, and 1.17, accounting for 65% of the total variance. Factor I accounted for 30% of the variance, Factor II for 16%, Factor III for 10%, and Factor IV for 9%. Factor scores were obtained via Principal Axis Factor Analysis with Direct Oblimin rotation and Kaiser normalization. Factors were not constrained for orthogonality. The only significant correlation among the four factors was between Factor I and Factor III (r = -.31, p \ .001). As shown in Table 2, eight measures had loadings of |.30| or greater on one factor only, whereas five measures had loadings of |.30| or higher on two or more factors. Moreover, the five measures (Type D negative affectivity, Type D social inhibition, depressive symptoms, worry, avoidant coping) with loadings of |.30| or greater on two or more factors appear to tap anxious/dysphoric feelings and behaviour. Self-criticism, support dissatisfaction, and aggression/anger/hostility loaded mainly on Factor I (Anger toward Self and Others), which was strongly associated with anxious/dysphoric feelings and behavior (negative affectivity, social inhibition, depressive symptoms, worry, avoidant coping). Problem-focused coping,

Table 2 Factor loadings Oblimin rotated factors Measures

I

II

III

IV -.11

Self-criticism

.85

-.04

-.18

Personal standards

.23

.42

-.08

.12

Dependency

.10

.04

-.70

-.17

Aggression/anger/hostility

.54

.04

-.09

-.18

Type D negative affectivity

.78

-.37

-.52

-.04

Type D social inhibition

.31

-.36

-.30

-.30

Depressive symptoms Worry

.66 .61

-.15 -.05

-.44 -.67

-.42 .00

.46

.01

-.11

-.34

Problem-focused coping

Avoidant coping

-.11

.81

.04

.14

Positive reinterpretation

-.09

.80

.02

-.10

.57

-.11

-.27

.03

-.15

.10

.17

.62

Support dissatisfaction Physical functioning

Factor loadings equal to or greater than |.30| in magnitude are italicized to denote loadings of potential theoretical significance N = 123

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positive reinterpretation, and personal standards loaded mainly on Factor II (Optimistic Self-Assertion), which had a moderate inverse association with anxious/dysphoric feelings/behaviour (negative affectivity, social inhibition). Dependency had a negative loading mainly on Factor III (Dependency/Relationship Loss Concerns), with lower scores on this factor linked to anxious/dysphoric feelings/ behaviour (negative affectivity, social inhibition, depressive symptoms, worry). Finally, physical functioning loaded mainly on Factor IV (Perceived Physical Capability), which had a moderate inverse association with anxious/ dysphoric feelings/behaviour (social inhibition, depressive symptoms, avoidant coping). Hierarchical Multiple Regressions Nine hierarchical multiple regression analyses were performed to assess the incremental associations of self-criticism, personal standards, and dependency with aggression/ anger/hostility, negative affectivity, social inhibition, depressive symptoms, worry, avoidant coping, positive reinterpretation, problem-focused coping, and support dissatisfaction, respectively, over and above the effects of the other personality vulnerability variables (aggression/anger/ hostility, negative affectivity, social inhibition). Because physical functioning could possibly explain the intercorrelations among the variables (e.g., Siegman, Townsend, Civelek, & Blumenthal, 2000), the SF-36 physical functioning scale along with sex and age were entered as the first step in each regression to remove the variance associated with levels of physical functioning, sex, and age. Gensini ratings of CAD severity were not used as a covariate or predictor because, as expected, CAD severity was not significantly associated with any of the personality vulnerability, psychosocial adjustment, or physical functioning variables. Aggression/anger/hostility, Type D negative affectivity, and Type D social inhibition were entered in the second step. Finally, self-criticism, personal standards, and dependency were entered in the third step. As shown in Table 3, the first block of variables (physical functioning, sex, age) failed to account for unique variance across the personality vulnerability measures and psychosocial outcomes, with exception to social inhibition and depressive symptoms. The second block of previously established personality vulnerability variables in CAD (aggression/anger/hostility, Type D negative affectivity, Type D social inhibition) accounted for large amounts (ranging from 13 to 36%) of incremental variance over and above the first block of variables in relation to all of the personality vulnerability measures and psychosocial outcomes. Among the variables of the second block, negative affectivity demonstrated the most consistent unique associations (see Table 3). Finally, as shown in Table 3, the

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Table 3 Hierarchical regression analyses examining incremental validity of self-criticism, personal standards, and dependency in predicting aggression/anger/hostility, type D personality dimensions, and psychosocial outcomes Variable

Aggression/anger/ hostility DR2

b Step 1 Physical functioning Sex Age

Type D negative affectivity Type D social inhibition

Personal standards Dependency

.03

– .43***

.12

.41***

.06* .10

b

DR

Step 1

.01

2

-.02 .13

2

b

DR

.04

.64*** –.01 .07**

.08

Problem-focused coping

Positive reinterpretation b

DR

.05

2

.12 .31*** Support dissatisfaction DR2

b

.02

.04

-.14

-.01

-.09

-.08

Sex

-.02

-.12

-.11

-.16

Age

.11

Aggression/anger/hostility

-.17 .14***

.21*

-.10 .13***

-.14 .14***

.19a

.22*

.30*** -.01

Type D negative affectivity

.14

-.27*

-.36***

.52***

Type D social inhibition

.18

-.20*

-.11

.09

Step 3 Self-criticism Personal standards Dependency

.03 .17 .08 -.05

.07* -.02

.08* .03

.15*** .26**

Physical functioning

Step 2

.36*** -.07

.36***

-.08

.21**

-.14 .29***

.49***

–.00

-.17*

-.08

.02 -.12 .02

.02

.22*** .51***

.15***

.12



DR2

b

-.04

-.03

.35***

.24*

DR2

b

.15***



Worry

-.38*** .03

.29*** .37***

–.03

Depressive symptoms

.07* -.11 .14

-.09 .17***

Avoidant coping Variable

DR2

b

-.17 -.13

.07

Step 3 Self-criticism

Type D social inhibition

DR2

b

.04 -.13 -.16

Step 2 Aggression/anger/hostility

Type D negative affectivity

.03 .23*

.23*

.18a

-.04

.11

.19*

-.02

N = 123 a

p \ .054; * p \ .05; ** p \ .01; *** p \ .001

third block containing self-criticism, personal standards, and dependency as predictors accounted for significant incremental variance in aggression/anger/hostility (6%), negative affectivity (22%), depressive symptoms (7%), worry (15%), problem-focused coping (7%), and positive reinterpretation (8%) over and above the first and second blocks of variables. Within these third blocks, self-criticism demonstrated a significant unique association with aggression/anger/hostility, negative affectivity, depressive symptoms, worry, and support dissatisfaction. On the other hand, personal standards demonstrated a unique association with problem-focused coping, with a unique association with positive reinterpretation almost significant (p \ .054). Finally, dependency exhibited unique associations with negative affectivity and worry.

Discussion The present study builds on previous findings demonstrating hostility and Type D personality as predictors of negative prognosis in CAD (Razzini et al., 2008) by illuminating perfectionism dimensions and dependency as specific cognitive-personality vulnerability factors that might add new explanatory power to the understanding of numerous problem areas in CAD patients. Although previous findings demonstrated the differential associations of self-criticism and personal standards dimensions of perfectionism and dependency with various manifestations of psychosocial adjustment in various student, community, and psychiatric populations (see Dunkley et al., 2006a; Stoeber & Otto, 2006; Zuroff et al., 2004b), the present

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study is the first to consider perfectionism dimensions and dependency in the context of CAD. In considering the role of perfectionism and dependency in CAD outcomes, our study highlights the differential relevance of self-criticism and personal standards dimensions of perfectionism and dependency in relation to aggression/anger/hostility, Type D personality, and various psychosocial outcomes (e.g., depressive symptoms, worry, coping, support dissatisfaction) that have been previously established as predictors of outcome in CAD (e.g., Razzini et al., 2008; Rozanski et al., 1999). As expected, self-criticism exhibited moderate to strong correlations (see Table 1) with personality vulnerability (aggression/anger/hostility, Type D negative affectivity) and psychosocial maladjustment (depressive symptoms, worry, avoidant coping, support dissatisfaction). These results are consistent with previous evidence associating self-criticism with a broad range of psychosocial problems in various populations (see Blatt, 2004; Dunkley et al., 2006a; Zuroff et al., 2004a). Further, self-criticism was only associated with maladaptive correlates and was unrelated to adaptive forms of coping, such as problemfocused coping and positive reinterpretation. Thus, selfcritical individuals experience aggression/anger/hostility, negative affectivity, depressive symptoms, worry, avoidant coping, and support dissatisfaction without the use of adaptive coping mechanisms to help provide a respite from their maladaptive tendencies (Dunkley et al., 2003). In contrast, personal standards showed significant zeroorder correlations with adaptive coping, namely problemfocused coping and positive reinterpretation, and the maladaptive outcome, worry (see Table 1). The results are consistent with evidence associating personal standards with both adaptive and maladaptive aspects of functioning (e.g., Dunkley et al., 2000, 2006a). Although worry has been previously implicated in the outcome of CAD (Kubzansky et al., 1997), the negative impact of the correlation between personal standards and worry might be offset by the tendency for individuals with higher personal standards to engage in adaptive coping (Dunkley et al., 2000). Dependency exhibited significant zero-order correlations with negative affectivity, social inhibition, depressive symptoms, and worry, which, consistent with previous research (see Zuroff et al., 2004a), were weaker than the corresponding correlations for self-criticism. Finally, aggression/anger/hostility, Type D negative affectivity, and Type D social inhibition were all associated with depressive symptoms, worry, avoidant coping, and support dissatisfaction; however, only the Type D personality dimensions were associated with lower adaptive coping (problem-focused coping, positive reinterpretation). Thus, maladaptive coping might contribute to the negative outcomes associated with Type D dimensions (Martin et al., 2011).

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The factor analytic results identified four common factors that underlie the correlational results and provided a clearer picture of underlying processes and interrelations among the measures. Eight of the 13 measures demonstrated specificity in loading mainly on one factor, whereas the other five measures appeared to tap anxious/dysphoric feelings and behaviour that were relatively more nonspecific in loading across two or more factors (see Table 2). Factor I represented anger towards the self and others, which was reflected by self-criticism, aggression/anger/ hostility, and support dissatisfaction loading mainly on this factor that had strong associations with anxious/dysphoric feelings and behavior (negative affectivity, social inhibition, depressive symptoms, worry, avoidant coping). Factor II represented optimistic self-assertion, which was reflected by problem-focused coping, positive reinterpretation, and personal standards loading mainly on this factor that had a moderate inverse association with anxious/dysphoric feelings/behaviour (negative affectivity, social inhibition). Factor III represented dependency/relationship loss concerns, which was reflected by dependency loading mainly on this factor that was also linked to anxious/dysphoric feelings/behaviour (negative affectivity, social inhibition, depressive symptoms, worry). Finally, Factor IV reflected perceived physical capability, which was indicated by physical functioning loading mainly on this factor that had a moderate inverse association with anxious/dysphoric feelings/behaviour (social inhibition, depressive symptoms, avoidant coping). Thus, the factor analytic results further differentiated self-criticism, personal standards, and dependency, and highlighted the potential heuristic value of these specific cognitive-personality dimensions in gaining a more detailed understanding of individual differences in psychosocial (mal)adjustment in CAD patients. An important contribution of our study is demonstrating that self-criticism, personal standards, and dependency are neither equivalent, nor reducible, to other personality vulnerability factors in CAD (see Smith & MacKenzie, 2006; Suls & Bunde, 2005). Previously established personality vulnerability variables in CAD (aggression/anger/hostility, Type D negative affectivity, Type D social inhibition) accounted for substantial amounts (ranging from 13 to 36%) of incremental variance in relation to all of the personality vulnerability measures and psychosocial outcomes, with negative affectivity exhibiting the most consistent unique associations (see Table 3). Despite the large amounts of variance in outcomes already accounted for, the hierarchical regression results demonstrated the incremental relation between self-criticism and each of depressive symptoms and support dissatisfaction over and above aggression/anger/hostility, negative affectivity, and social inhibition, which is consistent with previous research (see Zuroff et al., 2004a). The present study expanded on

J Clin Psychol Med Settings (2012) 19:211–223

previous work by demonstrating the incremental validity of perfectionism dimensions and dependency in relation to other problem areas in CAD patients, including aggression/ anger/hostility, negative affectivity, and worry. Specifically, self-criticism was uniquely related to aggression/ anger/hostility over and above the effects of Type D negative affectivity and Type D social inhibition. Similarly, the associations of both self-criticism and dependency with negative affectivity remained significant after controlling for the effects of aggression/anger/hostility and social inhibition. Further, both self-criticism and dependency remained significantly related to worry controlling for the effects of aggression/anger/hostility, negative affectivity, and social inhibition. In addition, personal standards was also uniquely associated with problem-focused coping and positive reinterpretation (an almost significant trend), which suggests that personal standards could potentially play a protective role in CAD adjustment. Overall, the factor analytic and multiple regression findings support the differential importance of both broad (e.g., negative affectivity) and specific (e.g., self-criticism) personality vulnerability dimensions in relation to psychosocial (mal)adjustment in CAD patients, which is in keeping with previous findings (see Zuroff et al., 2004a). Moreover, our results suggest that self-criticism and personal standards dimensions of perfectionism and dependency have differential associations with personality vulnerability and psychosocial (mal)adjustment in CAD patients. The combined findings from the two methods of analysis extend and deepen our theoretical understanding by indicating that broad personality vulnerability dimensions are pertinent to a wide variety of psychosocial problems, but more narrowly defined personality vulnerability dimensions can provide a more nuanced understanding of psychosocial (mal)adjustment in CAD patients. In considering specific cognitive-personality vulnerability in CAD patients, these findings highlight the importance of distinguishing between perfectionism dimensions and dependency. Our findings suggest that it might not be necessary to address personal standards in CAD patients because having high personal standards does not appear to be maladaptive in and of itself (e.g., Dunkley et al., 2006a; Stoeber & Otto, 2006). Rather, efforts to improve the clinical care of CAD patients might include the assessment and treatment of self-critical and dependent tendencies in order to help alleviate a broad range of psychosocial maladjustment in CAD patients. For example, potential interventions might attempt to reduce self-criticism with cognitive restructuring and behavioural experiments that target inherent difficulties in self-soothing and counteracting self-attacks (e.g., Kelly, Zuroff, & Sapira, 2009), whereas potential interventions to reduce dependency might attempt to change thoughts about being

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helpless or unloved (e.g., Beck, 1999). Future research should explore whether reducing self-criticism and dependency, and their associated maladaptive tendencies influence various CAD outcomes. Several limitations within the study warrant attention in future research. First, in order to limit participant burden, the self-criticism and personal standards dimensions of perfectionism were each measured by one particular instrument, namely the MDEQ and FMPS, respectively. It would be informative to examine whether similar findings would emerge using other measures of self-criticism and personal standards dimensions (e.g., Frost et al., 1990; Hewitt & Flett, 1991; Dunkley et al., 2006a; Stoeber & Otto, 2006). Second, the cross-sectional nature of this study does not allow for statements about a causal relation between self-criticism/dependency, psychosocial maladjustment, and CAD. It is possible, for example, that aggression/anger/hostility, depressive symptoms, worry, and support dissatisfaction influenced the reports of selfcriticism. A longitudinal study that incorporates multiple clinical assessments across time is needed to help clarify this relationship. Third, as the present study was an initial foray into establishing a unique association between selfcriticism and various psychosocial maladjustment outcomes in CAD, an important next step for future research will be to examine potential mediating mechanisms (e.g., avoidant coping) in the relation between self-criticism and psychosocial maladjustment (e.g., depression) over time (e.g., Dunkley et al., 2003). Fourth, because assessments were based on self-report measures, replication with other methods of data-collection (e.g., clinical interviews) would be beneficial. Fifth, as the present study focuses on the relations of self-criticism, personal standards, and dependency with psychosocial (mal)adjustment, it is important for future research to examine the role of perfectionism dimensions and dependency in predicting cardiac events in CAD patients over time. Indeed, recent findings suggest that perfectionism dimensions and neuroticism are uniquely associated with mortality in older adults (Fry & Debats, 2009). Finally, we speculate that the effects of perfectionism dimensions and dependency are not limited to CAD, but likely extend to other vascular diseases such as stroke (Glassman & Shapiro, 1998). Future studies should examine the utility of the distinction between self-criticism, personal standards, and dependency in the context of other physical illnesses. In summary, the present findings suggest that self-criticism and personal standards dimensions of perfectionism and dependency add unique explanatory power in relation to numerous previously established personality vulnerability factors and psychosocial outcomes in CAD. The fact that self-criticism, personal standards, and dependency were uniquely associated with several pertinent personality

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and psychosocial variables in CAD raises the possibility that specific cognitive-personality dimensions might be important to consider in the early identification of patients who tend to experience a wide range of manifestations of psychosocial stress over time and, hence, might be especially vulnerable to experience cardiac events (see Rozanski et al., 1999). Acknowledgments This study was supported by funding from the Fonds de la Recherche en Sante´ du Que´bec (FRSQ). The investigators were supported by salary awards from the FRSQ (DD and KL) and graduate scholarship awards from the FRSQ and the Canadian Institutes of Health Research (AP). The authors gratefully acknowledge Dr. David Langleben and Anna Picolo for their support in the data collection.

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