Perfectionism dimensions as predictors of symptom ... - Guilford Press

Perfectionism and OCD dimensions Martinelli et al.

Perfectionism dimensions as predictors of symptom dimensions of obsessive-compulsive disorder Mary Martinelli, MA Gregory S. Chasson, PhD Chad T. Wetterneck, PhD John M. Hart, PhD Thröstur Björgvinsson, PhD The correlation between obsessive-compulsive disorder (OCD) and perfectionism is well documented, yet it remains unclear if dimensions of perfectionism vary as a function of OCD symptom dimensions. To this end, the present study investigated the unique associations between dimensions of perfectionism (i.e., concern over mistakes, doubts about actions, personal standards, parental criticism, parental expectations, and organization) and OCD symptom dimensions (i.e., hoarding, washing, checking, ordering, obsessing, and neutralizing). The study included adult patients with OCD (N = 46) from a residential OCD treatment program. Consistent with previous research, doubts about actions was a significant predictor of overall OCD severity and OCD checking symptoms. The organization dimension of perfectionism was a significant predictor of OCD ordering symptoms. The current study provides evidence for the unique relationships between OCD symptoms and perfectionism dimensions that encourage a movement toward greater phenotypic specificity within existing models of OCD. (Bulletin of the Menninger Clinic, 78[2], 140–159)

Mary Martinelli and Gregory S. Chasson are at Towson University, Towson, Maryland. Chad T. Wetterneck is with the Houston OCD Program and Rogers Memorial Hospital. John M. Hart is with the Houston OCD Program and the Menninger Clinic. Thröstur Björgvinsson is with the Houston OCD Program and McLean Hospital/Harvard Medical School. Correspondence may be sent to Gregory S. Chasson, PhD, Department of Psychology, Towson University, 8000 York Road, Towson, MD 21252; e-mail: gchasson@gmail. com (Copyright © 2014 The Menninger Foundation)

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Perfectionism and OCD dimensions

Various theoretical perspectives have linked obsessive-compulsive disorder (OCD) and perfectionism since as early as the 1900s. Early theorists posited that perfectionism was central to the development of OCD. They believed that pathological perfectionism led to an insistence on doing things just right—so much so that it became an obsession and a way to avoid uncertainty (Frost, Novara, & Rhéaume, 2002). Since then, theories have ranged from describing perfectionism as simply a characteristic of OCD, to a belief system leading to OCD tendencies, to a direct cause that, when combined with a need for certainty, leads to the onset of OCD (Frost et al., 2002). Coinciding with theory development, significant empirical research has examined the link between perfectionism and OCD phenomenology. The research tends to fall into three main areas of inquiry: (1) relationship between OCD dimensions and overall perfectionism, (2) link between overall OCD severity and various dimensions of perfectionism, and (3) associations between perfectionism dimensions and select OCD phenotypes (e.g., those with checking symptoms; Moretz & McKay, 2009). OCD symptom dimensions and overall perfectionism

In studies with clinical samples, higher perfectionism/certainty beliefs were associated with greater symmetry symptoms (Calamari et al., 2006; Viar, Bilsky, Armstrong, & Olatunji, 2011; Wheaton, Abramowitz, Berman, Riemann, & Hale, 2010), ordering symptoms (Calleo, Hart, Björgvinsson, & Stanley, 2010; Tolin, Brady, & Hannan, 2008), hoarding and obsessing (Tolin et al., 2008), and checking behaviors (Julien, O’Connor, Aardema, & Todorov, 2006). Research using nonclinical samples demonstrated that perfectionism/certainty beliefs were associated with washing, checking, and ordering symptoms (Myers, Fisher, & Wells, 2008; Wu & Cortesi, 2009). Other work with nonclinical college samples suggests that maladaptive perfectionism (i.e., those perfectionism dimensions that promote dysfunction or distress) was associated with greater checking (Ashby & Bruner, 2005; Rice & Pence, 2006), doubting, and slowness symptoms

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(Ashby & Bruner, 2005) relative to adaptive perfectionism (i.e., those perfectionism dimensions that tend to promote well-being). Most studies on OCD symptom dimensions and overall perfectionism are limited, however, by use of the Obsessive Beliefs Questionnaire (OBQ), which measures three empirically derived dimensions of obsessive-compulsive (OC) beliefs, including a dimension called perfectionism/certainty (i.e., exhibiting a perfectionist worldview and a need for certainty; Obsessive Compulsive Cognitions Working Group, 2005). Thus, the OBQ conflates perfectionism with a need for certainty, which makes it difficult to interpret the link between perfectionism and symptom dimensions of OCD. Aside from reliance on the OBQ, another limitation of existing research on the link between OCD dimensions and total perfectionism is the use of undergraduate participants. Research with undergraduate samples may be difficult to generalize to clinical populations, suggesting a need for research that enrolls participants with OCD. OCD severity and perfectionism dimensions

Research addressing the relationships between OCD severity and dimensions of perfectionism often utilize the Frost Multidimensional Perfectionism Scale (FMPS; Frost, Marten, Lahart, & Rosenblate, 1990), which includes six dimensions of perfectionism: Concern over Mistakes (CM; interpretations of mistakes as failures), Personal Standards (PS; extent to which individuals set high standards for themselves), Parental Criticism (PC; extent to which parents were excessively critical), Parental Expectations (PE; socially prescribed high expectations), Doubts about Actions (DA; amount of confidence individuals have about their ability to complete tasks), and Organization (O; extent to which individuals place importance on orderliness). The PE and PC dimensions of perfectionism were included in order to account for research evidence that suggests that parental criticism and expectations may be etiologically associated with the development of perfectionism and self-evaluations in children (e.g., Frost, Lahart, & Rosenblate, 1991). The maladaptive dimensions of perfectionism

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are CM, DA, PE, and PC, whereas the adaptive dimensions are PS and O (Frost, Heimberg, Holt, Mattia, & Neubauer, 1993). It is important to note that although there is support for the original six dimensions of perfectionism as a valid factor structure on the FMPS (e.g., Purdon, Antony, & Swinson, 1999), other proposed factor structures have also received empirical support. For example, Stöber (1998) found statistical support for a fourfactor structure of the FMPS, which combines the PE and PC as well as the CM and DA dimensions of perfectionism. Stallman and Hurst (2011) found support for a five-factor structure, which collapsed the two parental dimensions of perfectionism. The two latter proposed factor structures, however, were determined using university, rather than clinical, samples. Studies examining all subscales of the FMPS have found that individuals with OCD, compared to nonclinical controls, exhibit higher DA scores (Antony, Purdon, Huta, & Swinson, 1998; Frost & Steketee, 1997; Lee et al., 2009), CM scores (Antony, Purdon, et al., 1998; Frost & Steketee, 1997; Lee et al., 2009; Libby, Reynolds, Derisley, & Clark, 2004), PE scores (Libby et al., 2004), and PC scores (Lee et al., 2009). In addition, people with OCD score higher on DA (Antony, Purdon, et al., 1998; Frost & Steketee, 1997), CM, PE, and PC (Antony, Purdon, et al., 1998) compared to people with other types of anxiety disorders. A significant relationship between the DA dimension of perfectionism and OCD severity also was demonstrated in a study on OCD personality traits (Wetterneck et al., 2011). These findings may have implications for treatment, because higher levels of perfectionism have been associated with worse treatment outcome in patients with OCD. In particular, Chik, Whittal, and O’Neill (2008) found that higher DA scores uniquely predicted poorer treatment outcome in OCD patients who received Exposure and Response Prevention, the gold standard psychological treatment for OCD. Interestingly, overall perfectionism scores (rather than DA alone) did not predict treatment response. These results further suggest the need for research on the role of specific perfectionism dimensions to increase understanding of OCD etiology and address implications for OCD treatment.

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Perfectionism dimensions and select OCD phenotypes

Research on dimensions of perfectionism and specific OCD phenotypes has focused mainly on Not Just Right Feelings (NJRFs) and sensory phenomena, although some studies have examined checking, hoarding, and ordering symptoms. A manifestation of OCD, NJRFs refer to a sensation of task incompletion or incorrectness (Coles, Frost, Heimberg, & Rhéaume, 2003). Conceptually similar, sensory phenomena are characterized by urges or a need to repeat activities until completed perfectly, and they serve as antecedents to compulsions (Lee et al., 2009). While the distinction between the two constructs of NJRFs and sensory phenomena is not yet clear, both seem to deviate from more traditional conceptualizations of OCD that focus largely on intrusive thoughts compared to intrusive urges. Some research has highlighted a link between dimensions of perfectionism and NJRFs, as well as between certain dimensions of perfectionism and sensory phenomena. According to a study by Coles et al. (2003), which enrolled a sample of undergraduate participants, NJRFs most strongly related to control and checking features of OCD, and NJRFs of higher intensity and importance were related to two maladaptive FMPS dimensions of perfectionism—CM and DA. Using an undergraduate sample, Moretz and McKay (2009) tested a model in which trait anxiety was hypothesized to mediate the relationship between certain perfectionism dimensions and NJRFs. Specifically, they derived a latent variable from four of the FMPS dimensions characterized by maladaptive evaluation concerns: DA, CM, PE, and PC. Results from the study confirmed the mediation effect, highlighting specific associations between perfectionism—characterized by maladaptive evaluation concerns—and NJRFs. Lee et al. (2009) explored the relationships between all FMPS dimensions and sensory phenomena. Enrolling 47 participants with OCD and 42 healthy controls, Lee and colleagues found that “just right” sensory phenomena were associated with DA, PS, and O when both study groups were combined. Thus, multiple perfectionism domains may be related to NJRFs and sensory phenomena, most commonly the DA dimension.

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Aside from NJRFs and sensory phenomena, certain perfectionism domains have been linked specifically to other OCD symptoms. Moretz and McKay (2009) supported a model in which trait anxiety mediated the relationship between a latent predictor—characterized by DA, CM, PE, and PC—and checking symptoms. In the study by Wetterneck et al. (2011), which enrolled a sample of 51 inpatients with OCD, DA correlated with various dimensions of OCD. Results indicated a statistically significant link between DA and both checking and ordering, two symptoms of OCD that have been linked to NJRFs (Coles et al., 2003). In addition, DA was associated with hoarding symptoms (Wetterneck et al., 2011), a finding that has been demonstrated in previous research by Frost and Gross (1993), in which a sample of individuals with hoarding scored significantly higher compared to healthy controls on CM, PS, PE, PC, and DA. Although some studies have examined subsets of perfectionism and OCD dimensions based on extant theory (e.g., Coles et al., 2003; Lee et al., 2009, Moretz & McKay, 2009), it remains unclear whether perfectionism dimensions relate to other OCD dimensions. Indeed, to our knowledge, no studies have explored the patterns of relationships between multiple perfectionism dimensions and multiple OCD symptom dimensions simultaneously. Identifying specific relationships between perfectionism domains and OCD symptom domains is critical for further characterizing the considerable phenotypic variability in OCD. Distinct associations between perfectionism dimensions and OCD symptoms may also highlight differential pathways that cause or maintain OCD. The aforementioned body of research has provided evidence for links between (1) particular OCD dimensions and perfectionism in general, (2) overall OCD severity and specific facets of perfectionism, and (3) perfectionism dimensions and select OCD phenotypes; however, the next crucial inquiry involves considering how these distinct dimensions of perfectionism and OCD symptoms are related in the service of better understanding the phenotypic variability of OCD. Thus, we investigated associations between OCD dimensions and perfectionism dimensions while addressing common limitations in the existing research literature by (1) measuring per-

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fectionism using the FMPS rather than the OBQ, (2) enrolling a clinical sample of patients with OCD, and (3) using regression models instead of correlation analysis, allowing for investigation of the specific effects of unique variance among perfectionism dimensions when predicting OCD symptoms. Based on the above-mentioned research, we predicted that the DA, CM, PE, and PC subscales would be significant unique predictors of OCD checking behaviors and that DA would significantly and uniquely predict both hoarding and ordering symptoms. Methods Participants The sample included a subgroup of adults with OCD who were admitted to a residential OCD treatment program at the Menninger Clinic during 2005 and 2006 and who completed the FMPS. Only individuals with a primary (N = 37) or secondary (N = 9) OCD diagnosis were included in the study. Diagnoses were established by a multidisciplinary treatment team consisting of psychiatrists, psychologists, and behavior therapists experienced in OCD diagnosis and treatment who met to review relevant clinical data, including medical records, questionnaire responses, and unstructured clinical interviews. Individuals in the final sample with a primary OCD diagnosis had comorbid secondary diagnoses, including major depressive disorder, recurrent (n = 19); generalized anxiety disorder (n = 2); social phobia (n = 2); schizophrenia, disorganized type (n = 1); bipolar II disorder (n = 1); Asperger’s disorder (n = 1); depersonalization disorder (n = 1); body dysmorphic disorder (n = 1); borderline personality disorder (n = 1); and polysubstance dependence (n = 1). For individuals with a secondary diagnosis of OCD, comorbid primary diagnoses for the sample included social phobia (n = 3), generalized anxiety disorder (n = 2), borderline intellectual functioning (n = 1), Asperger’s disorder (n = 1), Tourette’s disorder (n = 1), and eating disorder NOS (n = 1). The sample included both male (n = 22) and female (n = 24) adults with ages ranging from 18 to 52 years old (mean age = 31.93, SD = 10.1).

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Measures Frost Multidimensional Perfectionism Scale (FMPS). As described previously, the FMPS (Frost et al., 1990) is a 35-item selfreport questionnaire that assesses the six aforementioned dimensions of perfectionism. Items are rated on a 5-point Likert scale (strongly disagree to strongly agree). Therefore, higher scores on the subscales indicate higher levels of that dimension of perfectionism. The internal consistencies for FMPS subscales ranged from good to excellent (Cronbach’s α: PS = .82; DA = .82; PC = .85; O = .88; PE = .91; CM = .92). The FMPS has demonstrated satisfactory convergent and discriminatory validity (Frost et al., 1990). The Obsessive-Compulsive Inventory-Revised (OCI-R). The OCI-R (Foa et al., 2002) was used to assess OCD symptom dimensions. The OCI-R is an 18-item self-report questionnaire that assesses six subscales of OCD symptoms: Washing, Obsessing, Hoarding, Ordering, Checking, and Neutralizing. Responses are measured using a 5-point Likert scale ranging from 0 (Not at all) to 4 (Extremely). Therefore, higher scores on the subscales indicate higher presence of those symptoms. The OCI-R has been shown to be a reliable and valid measure of OCD severity with sound internal consistency, test-retest reliability, and validity (Foa et al., 2002). Internal consistencies for the subscales ranged from adequate to excellent (Cronbach’s α: Ordering = .77; Neutralizing = .82; Hoarding = .82; Obsessing = .84; Checking = .86; Washing = .91). Procedures The patients were referred to the residential OCD treatment program by outpatient mental health professionals. Patients completed the FMPS and OCI-R as part of a larger intake battery involving routine clinical care. The Towson University Internal Review Board exempted and approved a redacted version of the data for use in secondary data analysis.

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Data analysis Before the main analyses, variables were assessed to ensure that they met data analytic assumptions. Linearity and homoscedasticity were confirmed through visual inspection of regression standardized residual plots. Multicollinearity was ruled out based on Variance Inflation Factor estimates falling well below conventional cutoffs. An initial correlation analysis was performed to assess the covariation between perfectionism dimensions and OCD symptoms. Linear regression models were then conducted in which each OCD symptom dimension was regressed on those FMPS dimensions with which it was significantly correlated. Regression models were run only for those OCD symptoms with two or more significantly correlated FMPS dimensions. We also included OCI-R Total and FMPS Total scores in the correlation analysis, and we carried out a linear regression for the total score of the OCI-R in order to replicate previous research. Despite the limited sample size, the study was sufficiently powered, as a priori power analysis suggested the inclusion of at least 41 participants. The analysis was based on α = .05, minimum power of .8, a maximum of six predictors for each perfectionism dimension, and a medium effect size (previous research indicates a moderate correlation between perfectionism and some OCD symptom dimensions—e.g., Wheaton et al., 2010). Results

Descriptive data and initial correlation analysis of the dimensions of perfectionism and OCD symptom dimensions are presented in Table 1, and results of the main effects for the regression models are provided in Table 2. Before the OCD symptom dimensions were examined, total score on the OCI-R was tested in a linear regression model. The total score was significantly correlated with the CM and DA dimensions of the FMPS; therefore those two variables were entered into the regression model as predictors. Results indicated a statistically significant model, F(2, 43) = 8.825, p < .001, R2 = .291. Evaluation of the main effects indicated that only the DA domain of perfectionism was a statistically significant predictor of total OCI-R score.

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27.59

14. OCI-R Total

13.37

3.33

2.96

3.18

3.79

22.25

5.46

4.93

5.58

5.45

.435**

.300*

−.034

.461**

.208

.375*

.263

.840**

.095

.383**

.605**

.473**

.572**

1

1.

.510**

.350*

.200

.413**

.228

.475**

.218

.483**

.086

.066

.285

.045

1

2.

.247

.230

−.283

.387**

−.050

.146

.360*

.760**

.281

.835**

.300*

1

3.

.195

.173

−.049

.074

.044

.104

.281

.680**

.222

.133

1

4.

.232

.241

−.258

.379**

.044

.102

.266

.646**

.129

1

5.

.144

.423**

−.214

.204

−.136

.234

.022

.447**

1

6.

.437**

.423**

−.174

.484**

.088

.348*

.355*

1

7

.601**

.162

.095

.286

.053

.312*

1

8.

.702**

.230

.406**

.381**

.221

1

9.

.543**

.265

.235

.247

1

10.

.680**

.574**

.064

1

11.

.491**

.146

1

12.

.619**

1

13.

1

14.

Note. FMPS CM = Frost Multidimensional Perfectionism Scale Concern Over Mistakes, FMPS DA = Frost Multidimensional Perfectionism Scale Doubts About Actions, FMPS PE = Frost Multidimensional Perfectionism Scale Parental Expectations, FMPS PS = Frost Multidimensional Perfectionism Scale Personal Standards, FMPS PC = Frost Multidimensional Perfectionism Scale Parental Criticism, and FMPS O = Frost Multidimensional Perfectionism Scale Organization; OCI-R Total = Obsessive-Compulsive Inventory-Revised Total Score, Washing = Obsessive-Compulsive Inventory-Revised Washing subscale score, Checking = Obsessive-Compulsive Inventory-Revised Checking subscale score, Neutralizing = Obsessive-Compulsive Inventory-Revised Neutralizing subscale score, Hoarding = Obsessive-Compulsive Inventory-Revised Hoarding subscale score, Obsessing = Obsessive-Compulsive Inventory-Revised Obsessing subscale score, Ordering = Obsessive-Compulsive Inventory-Revised Ordering subscale score. *p < .05, **p < .01.

6.28

4.65

12. Obsessing

13. Ordering

3.67

5.33

8. Washing

11. Hoarding

3.84

112.1

7. FMPS Total

4.52

21.26

6. FMPS O

3.13

10.20

5. FMPS PC

9. Checking

24.09

4. FMPS PS

10.Neutralizing

4.90

14.24

3. FMPS PE

3.30

14.63

2. FMPS DA

8.44

27.76

1. FMPS CM

SD

Table 1. Correlations, means, and standard deviations of perfectionism and OCD dimensions and total scores

Mean


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Martinelli et al. Table 2. Standardized regression weights and t test results of the main effects in the multiple regression models Predictor

OCI-R Checking

OCI-R Hoarding

OCI-R Ordering

OCI-R Total

(β) t

(β) t

(β) t

(β) t

FMPS CM

(.13) 0.78

(.14) 0.72

(.12) 0.77

(.21) 1.36

FMPS DA

(.40) 2.48*

(.32) 1.92

(.25) 1.56

(.39) 2.49*

FMPS PC

—

(.16) 0.69

—

—

FMPS PE

—

(.17) 0.69

—

—

FMPS O

—

—

(.39) 2.98**

—

Note. FMPS CM = Frost Multidimensional Perfectionism Scale Concern Over Mistakes, FMPS DA = Frost Multidimensional Perfectionism Scale Doubts About Actions, FMPS PC = Frost Multidimensional Perfectionism Scale Parental Criticism, FMPS PE = Frost Multidimensional Perfectionism Scale Parental Expectations, and FMPS O = Frost Multidimensional Perfectionism Scale Organization, OCI-R Total = Obsessive-Compulsive Inventory-Revised Total Score, Checking = Obsessive-Compulsive Inventory-Revised Checking subscale score, Hoarding = Obsessive-Compulsive Inventory-Revised Hoarding subscale score, Ordering = Obsessive-Compulsive InventoryRevised Ordering subscale score. *p < .05, **p < .01.

To examine OCD symptom dimensions individually, separate linear regressions were run for the Checking (with CM and DA as predictors), Hoarding (with CM, DA, PC, and PE as predictors), and Ordering (with O, CM, and DA as predictors) dimensions of the OCI-R. No regression models were run for the Neutralizing or Obsessing dimensions of the OCI-R because they were not significantly correlated with any subscales of the FMPS. Finally, no model was run for the Washing dimensions of the OCI-R because it was only correlated with the PE subscale of the FMPS. The first model regressed Checking on CM and DA and indicated a statistically significant model, F(2, 43) = 6.651, p < .01, R2 = .236. Evaluation of the main effects indicated that only the DA domain of perfectionism was a statistically significant predictor of checking symptoms. A second model regressed Hoarding on CM, DA, PC, and PE. Results indicated a statistically significant model, F(4, 41) = 4.864, p < .01, R2 = .332. Evaluation of the main effects, however, indicated that none of the domains of perfectionism were statistically significant predictors. The final model regressed Ordering on O, CM, and DA. Results indicated a statistically significant model, F(3, 42) = 5.668, p < .01, R2 = .288. Evaluation of the main effects indicated that only the O

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domain of perfectionism was a statistically significant predictor of ordering symptoms. Discussion

The present study examined the relationships between multiple obsessive-compulsive symptoms and the various dimensions of perfectionism. In addition to the significant relationship between DA and total OCI-R score, which was consistent with the previous research literature (Antony et al., 1998; Frost & Steketee, 1997; Lee et al., 2009), results confirmed part of our hypothesis that DA would uniquely predict checking symptoms. However, inconsistent with our hypotheses, PE and PC did not correlate with checking symptoms, nor was CM a unique predictor of checking. The DA dimension correlated with hoarding and ordering, but these effects disappeared when controlling for other perfectionism dimensions in the regression models. Available evidence, including findings from the current study, suggests that the DA dimension of perfectionism is tied to checking behavior, but the importance or specificity of DA may not generalize to other manifestations OCD. Indeed, while controlling for various other perfectionism dimensions, we did not find that DA was a statistically significant predictor of any OCD symptoms other than checking. Interestingly, the DA subscale of the FMPS was developed based on a construct characterized by uncertainty about task completion (Frost et al., 1990), and Frost and colleagues (2002) have noted that the DA subscale is closely related to an intolerance of uncertainty. This leaves open the possibility that the correlation between DA and checking may be largely explained by uncertainty during task completion. Further research is needed to clarify this possibility. Closely linked to the concept of uncertainty about task completion is memory confidence, particularly as it related to task completion (Rachman, 2002)—that is, doubting one’s memory for having completed a specific task. While it may seem intuitive

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that doubt about completing a task begets checking—a direction supported by some research (e.g., Cougle, Salkovskis, & Wahl, 2007; Nedeljkovic, Moulding, Kyrios, & Doron, 2009)—some experimental studies have demonstrated the opposite direction, namely that checking elicits doubt about completing tasks as characterized by decreases in memory confidence (Alcolado & Radomsky, 2011; Boschen & Vuksanovic, 2007; van den Hout & Kindt, 2003). Thus, the relationship between DA and checking symptoms may be reciprocal, and prospective studies of individuals with OCD that take particular care to measure memory confidence may provide more insight into the cause-and-effect patterns of these entwined constructs. Results from the current study may also be useful for evaluating previous findings, which have linked a specific OCD phenotype, NJRFs, with both checking features of OCD and the DA dimension of perfectionism (Coles et al., 2003). Given the growing body of research connecting DA and OCD checking symptoms, future research examining these two constructs would benefit from also evaluating the role of NJRFs. Indeed, identifying the specific relationships (e.g., mediation, moderation) among DA, checking, and NJRFs could be an important target of future research. On a more global level, the specific relationship between DA and checking symptoms may influence current conceptualizations of OCD, which has been characterized as a disorder of doubt (Alvarenga, Hounie, Mercadante, Miguel, & Conceição, 2007; Cefalu, 2010). Pathological doubt is especially common in individuals with OCD and has been conceptualized as possibly resulting from an intolerance of uncertainty (Tolin, Abramowitz, Brigidi, & Foa, 2003) and/or memory deficits/distrust (Ashbaugh & Radomsky, 2007; Dar, Rish, Hermesh, Taub, & Fux, 2000). Furthermore, research suggests that pathological doubt may be inherently linked to checking behaviors (Ashbaugh & Radomsky, 2007; Dar et al., 2000; Harkin & Kessler, 2009), because doubting the completion or accuracy of a task may propel individuals with OCD to check in order to allay their doubts (Harkin & Kessler, 2009). Checking is among the most common OCD symptoms, with over 80% of individuals with OCD having checking

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compulsions (Antony, Downie, & Swinson, 1998). Therefore, although DA has been linked to OCD severity in previous perfectionism studies (Antony, Purdon, et al., 1998; Lee et al., 2009; Wetterneck et al., 2011), the results of the current study suggest that these findings may be largely attributable to the relationship between DA and checking compulsions. Ultimately, labeling the whole construct of OCD as a disorder of doubt may be mischaracterizing a subset of individuals with OCD. The significant relationship between the DA subscale of perfectionism and checking symptoms of OCD has potentially important implications for OCD treatment. In a recent study, Chik et al. (2008) found that DA scores uniquely predicted poorer treatment outcome in OCD patients. Therefore, it is possible that OCD patients with a high degree of checking and high DA may be susceptible to poorer treatment outcomes and/or longer recovery times. Additional research is needed to explore this possibility further. It is unclear why CM, PC, and PE were not significant predictors of checking symptoms as in prior work (Moretz & McKay, 2009). It is possible that the discrepancy resulted from differences in a clinical versus student sampling. In addition, Moretz and McKay found that self-focused perfectionism dimensions (i.e., DA and CM) were more robust predictors of checking compared to parent-focused dimensions (i.e., PC and PE). Perhaps the distinction between self- and parent-focused dimensions is stronger in clinical samples compared to student samples, explaining why DA and CM (i.e., self-focused) were associated with checking, but not PC and PE (i.e., parent-focused). However, these explanations still do not explain the lack of effect for CM—a self-focused dimension—on checking. Another possibility is that unique contributions of CM, PC, and PE were too small to be detected using tests of statistical significance with the current sample size. Further research is needed to clarify the role of CM, PC, and PE in checking behavior, particularly using participants with OCD. It is unsurprising that ordering symptoms were significantly related to the Organization dimension of perfectionism. Indeed, when breaking down the items that constitute the O and ordering dimensions, many of the items on both subscales seem to

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correspond. For example, the FMPS O subscale contains three items like “I need things to be arranged in a particular order,” and the ordering symptom subscale is made up of five items such as “Neatness is very important to me.” Notwithstanding the conceptual overlap of items, these results indicate that ordering may be strongly motivated by a need for organization or symmetry (and/or vice versa). This finding has been supported in previous research (Wetterneck et al., 2011). In the current study, hoarding symptoms were predicted by a linear combination of variables, including CM, DA, PC, and PE, which are dimensions that have been associated with hoarding in past research (Frost & Gross, 1993). However, when controlling for each of these dimensions, we did not find that any of them were statistically significant predictors of hoarding symptoms. This suggests a great deal of overlap among these perfectionism indices when predicting hoarding symptoms, with no specific perfectionism dimension providing unique contributions to the model. Thus, although perfectionism has been linked to hoarding (Frost & Gross, 1993; Timpano et al., 2011) and hoarding correlates (e.g., compulsive buying; Kyrios, Frost, & Steketee, 2004), further research with bigger sample sizes may be needed to better characterize the relationship between hoarding and perfectionism. This study explored the relationship between dimensions of perfectionism and dimensions of OCD that have been previously unexamined. For example, in the current study, washing symptoms were only correlated with the Parental Expectations dimension of perfectionism. Further research is needed to determine how parents may influence the link between perfectionism and contamination OCD. With respect to washing symptoms, it may be the case that parents truly promote perfectionistic expectations of cleanliness with their children with OCD. Alternatively, perhaps individuals with OCD perceive their parents as promoting perfectionistic expectations of cleanliness when, in reality, they are not. On the one hand, previous research on the familiality of OCD dimensions has not identified contamination symptoms, or common correlates of contamination (e.g., disgust sensitivity), as particularly transmissible in families (Cullen et al.,

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2007; Taberner et al., 2012). On the other hand, some evidence suggests that contamination symptoms in probands predict parental perfectionism (Calvo et al., 2009). Future research might benefit from targeting both parental (e.g., mother and father’s perfectionism) and individual variables, such as cognitive representations of parental expectations (i.e., perceived expectations, regardless of their accuracy). This study was not without limitations. As a result of the sample size, we were required to restrict the investigation to analyzing the relationship between OCD symptoms and perfectionism dimensions without including additional variables of interest (e.g., depression; Wu & Cortesi, 2009) or control variables (e.g., primary versus secondary OCD diagnosis). Future studies should include relevant control and mediator variables that may further account for the relationships discussed in this study. For instance, other obsessive-compulsive beliefs (e.g., responsibility; Yorulmaz, Karanci, & Tekok-Kiliç, 2006), worry, and obsessive compulsive personality disorder (OCPD) correlates (e.g., flexibility; Wetterneck et al., 2011) could be helpful in unraveling the relationship between specific OCD symptoms and perfectionism dimensions. Also, the possible effect of other comorbid disorders associated with perfectionism (e.g., eating disorders, anxiety) should be explored, because perfectionism is considered a transdiagnostic problem that has been implicated in various disorders (Bieling, Summerfeldt, Israeli, & Antony, 2004). Therefore, further research should focus on isolating the extent to which these perfectionism dimensions are purely associated with OCD symptoms. Overall, the current study provides evidence for the relationships between OCD symptoms and unique perfectionism dimensions that encourage a movement toward greater phenotypic specificity within existing models of OCD. Because greater levels of perfectionism have been associated with poorer treatment outcomes for OCD patients (Chik et al., 2008), suggesting that perfectionism may be an obstacle to recovery in some patients, the present study is essential for further parsing out models of OCD in order to better understand, and therefore better treat, the complexities of OCD.

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References Alcolado, G. M., & Radomsky, A. S. (2011). Believe in yourself: Manipulating beliefs about memory causes checking. Behaviour Research and Therapy, 49(1), 42–49. Alvarenga, P. G., Hounie, A. G., Mercadante, M. T., Miguel, E. C., & Conceição, M. (2007). Obsessive-compulsive disorder: A historical overview. In E. A. Storch & G. R. Geffken (Eds.), Handbook of child and adolescent obsessive-compulsive disorder (pp. 1–15). Mahwah, NJ: Lawrence Erlbaum Associates. Antony, M. M., Downie, F., & Swinson, R. P. (1998). Diagnostic issues and epidemiology in obsessive-compulsive disorder. In R. P. Swinson, M. M. Antony, S. S. Rachman, & M. A. Richter (Eds.), Obsessive-compulsive disorder: Theory, research, and treatment (pp. 3–32). New York, NY: Guilford Press. Antony, M. M., Purdon, C. L., Huta, V., & Swinson, R. P. (1998). Dimensions of perfectionism across the anxiety disorders. Behaviour Research and Therapy, 36(12), 1143–1154. Ashbaugh, A. R., & Radomsky, A. S. (2007). Attentional focus during repeated checking influences memory but not metamemory. Cognitive Therapy and Research, 31(3), 291–306. Ashby, J. S., & Bruner, L. P. (2005). Multidimensional perfectionism and obsessive-compulsive behaviors. Journal of College Counseling, 8, 31–40. Bieling, P. J., Summerfeldt, L. J., Israeli, A. L., & Antony, M. M. (2004). Perfectionism as an explanatory construct in comorbidity of axis I disorders. Journal of Psychopathology and Behavioral Assessment, 26(3), 193–201. Boschen, M. J., & Vuksanovic, D. (2007). Deteriorating memory confidence, responsibility perceptions and repeated checking: Comparisons in OCD and control samples. Behaviour Research and Therapy, 45, 2098–2109. Calamari, J. E., Cohen, R. J., Rector, N. A., Szacun-Shimizu, K., Riemann, B. C., & Norberg, M. M. (2006). Dysfunctional belief-based obsessivecompulsive disorder subgroups. Behaviour Research and Therapy, 44(9), 1347–1360. Calleo, J. S., Hart, J., Björgvinsson, T., & Stanley, M. A. (2010). Obsessions and worry beliefs in an inpatient OCD population. Journal of Anxiety Disorders, 24, 903–908. Calvo, R., Lázaro, L., Castro-Fornieles, J., Font, E., Moreno, E., & Toro, J. J. (2009). Obsessive-compulsive personality disorder traits and personality dimensions in parents of children with obsessive-compulsive disorder. European Psychiatry, 24(3), 201–206. Cefalu, P. (2010). The doubting disease: Religious scrupulosity and obsessive-compulsive disorder in historical context. Journal of Medical Humanities, 31(2), 111–125. Chik, H. M., Whittal, M. L., & O’Neill, M. L. (2008). Perfectionism and treatment outcome in obsessive-compulsive disorder. Cognitive Therapy and Research, 32(5), 676–688.

156


Perfectionism and OCD dimensions Coles, M. E., Frost, R. O., Heimberg, R. G., & Rhéaume, J. (2003). “Not just right experiences”: Perfectionism, obsessive-compulsive features and general psychopathology. Behaviour Research and Therapy, 41, 681–700. Cougle, J. R., Salkovskis, P. M., & Wahl, K. (2007). Perception of memory ability and confidence in recollections in obsessive-compulsive checking. Journal of Anxiety Disorders, 21, 118–130. Cullen, B., Brown, C. H., Riddle, M. A., Grados, M., Bienvenu, O., HoehnSaric, R., & . . . Nestadt, G. (2007). Factor analysis of the Yale-Brown Obsessive Compulsive Scale in a family study of obsessive-compulsive disorder. Depression and Anxiety, 24(2), 130–138. Dar, R., Rish, S., Hermesh, H., Taub, M., & Fux, M. (2000). Realism of confidence in obsessive-compulsive checkers. Journal of Abnormal Psychology, 109(4), 673–678. Foa, E. B., Huppert, J. D., Leiberg, S., Langner, R., Kichic, R., Hajcak, G., & Salkovskis, P. M. (2002). The Obsessive-Compulsive Inventory: Development and validation of a short version. Psychological Assessment, 14(4), 485–496. Frost, R. O., & Gross, R. C. (1993). The hoarding of possessions. Behaviour Research and Therapy, 31(4), 367–381. Frost, R. O., Heimberg, R. G., Holt, C. S., Mattia, J. I., & Neubauer, A. L. (1993). A comparison of two measures of perfectionism. Personality and Individual Differences, 14, 119–126. Frost, R. O., Lahart, C. M., & Rosenblate, R. (1991). The development of perfectionism: A study of daughters and their parents. Cognitive Therapy and Research, 15(6), 469–489. Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R. (1990). The dimensions of perfectionism. Cognitive Therapy and Research, 14(5), 449–468. Frost, R. O., Novara, C., & Rhéaume, J. (2002). Perfectionism in obsessivecompulsive disorder. In R. O. Frost & G. Steketee (Eds.), Cognitive approaches to obsessions and compulsions: Theory, assessment, and treatment (pp. 91–105). Amsterdam, The Netherlands: Pergamon/Elsevier Science. Frost, R. O., & Steketee, G. (1997). Perfectionism in obsessive-compulsive disorder patients. Behaviour Research and Therapy, 35(4), 291–296. Harkin, B., & Kessler, K. (2009). How checking breeds doubt: Reduced performance in a simple working memory task. Behaviour Research and Therapy, 47(6), 504–512. Julien, D., O’Connor, K. P., Aardema, F., & Todorov, C. (2006). The specificity of belief domains in obsessive-compulsive symptom subtypes. Personality and Individual Differences, 41(7), 1205–1216. Kyrios, M., Frost, R. O., & Steketee, G. G. (2004). Cognitions in compulsive buying and acquisition. Cognitive Therapy and Research, 28(2), 241–258. Lee, J. C., Prado, H. S., Diniz, J. B., Borcato, S., da Silva, C., Hounie, A. G., . . . do Rosário, M. C. (2009). Perfectionism and sensory phenomena: Phenotypic components of obsessive-compulsive disorder. Comprehensive Psychiatry, 50(5), 431–436.

Vol. 78, No. 2 (Spring 2014)

157

Martinelli et al. Libby, S., Reynolds, S., Derisley, J., & Clark, S. (2004). Cognitive appraisals in young people with obsessive-compulsive disorder. Journal of Child Psychology and Psychiatry, 45(6), 1076–1084. Moretz, M. W., & McKay, D. (2009). The role of perfectionism in obsessivecompulsive symptoms: ‘Not just right’ experiences and checking compulsions. Journal of Anxiety Disorders, 23(5), 640–644. Myers, S. G., Fisher, P. L., & Wells, A. (2008). Belief domains of the Obsessive Beliefs Questionnaire-44 (OBQ-44) and their specific relationship with obsessive-compulsive symptoms. Journal of Anxiety Disorders, 22, 475–484. Nedeljkovic, N., Moulding, R., Kyrios, M., & Doron, G. (2009). The relationship of cognitive confidence to OCD symptoms. Journal of Anxiety Disorders, 23, 463–468. Obsessive Compulsive Cognitions Working Group. (2005). Psychometric validation of the Obsessive Beliefs Questionnaire and interpretation of intrusions inventory: Part 2, factor analyses and testing of a brief version. Behaviour Research and Therapy, 43(11), 1527–1542. Purdon, C., Antony, M. M., & Swinson, R. P. (1999). Psychometric properties of the Frost Multidimensional Perfectionism Scale in a clinical anxiety disorders sample. Journal of Clinical Psychology, 55(10), 1271–1286. Rachman, S. S. (2002). A cognitive theory of compulsive checking. Behavior Research and Therapy, 40(6), 624–639. Rice, K. G., & Pence, S. L. (2006). Perfectionism and obsessive-compulsive symptoms. Journal of Psychopathology and Behavioral Assessment, 28(2), 103–111. Stallman, H., & Hurst, C. (2011). The factor structure of the Frost Multidimensional Perfectionism Scale in university students. Australian Psychologist, 46(4), 229–236. Stöber, J. (1998). The Frost Multidimensional Perfectionism Scale revisited: More perfect with four (instead of six) dimensions. Personality and Individual Differences, 24(4), 481–491. Taberner, J., Fullana, M. A., Caseras, X., Pertusa, A., Bados, A., van den Bree, M., & Torrubia, R. (2012). Familial predictors of obsessive-compulsive symptom dimensions (contamination/cleaning and symmetry/ ordering) in a nonclinical sample. Journal of Clinical Psychology, 68(12), 1266–1275. Timpano, K. R., Exner, C., Glaesmer, H., Rief, W., Keshaviah, A., Brahler, E., & Wilhelm, S. (2011). The epidemiology of the proposed DSM-5 hoarding disorder: Exploration of the acquisition specifier, associated features, and distress. Journal of Clinical Psychiatry, 72(6), 780–786. Tolin, D. F., Abramowitz, J. S., Brigidi, B. D., & Foa, E. B. (2003). Intolerance of uncertainty in obsessive-compulsive disorder. Journal of Anxiety Disorders, 17(2), 233–242. Tolin, D. F., Brady, R. E., & Hannan, S. (2008). Obsessional beliefs and symptoms of obsessive-compulsive disorder in a clinical sample. Journal of Psychopathology and Behavioral Assessment, 30(1), 31–42. van den Hout, M., & Kindt, M. (2003). Repeated checking causes memory distrust. Behaviour Research and Therapy, 41, 301–316.

158


Perfectionism and OCD dimensions Viar, M. A., Bilsky, S. A., Armstrong, T., & Olatunji, B. O. (2011). Obsessive beliefs and dimensions of obsessive-compulsive disorder: An examination of specific associations. Cognitive Therapy and Research, 35, 108–117. Wetterneck, C. T., Little, T. E., Chasson, G. S., Smith, A. H., Hart, J. M., Stanley, M. A., & Björgvinsson, T. (2011). Obsessive-compulsive personality traits: How are they related to OCD severity? Journal of Anxiety Disorders, 25(8), 1024–1031. Wheaton, M. G., Abramowitz, J. S., Berman, N. C., Riemann, B. C., & Hale, L. R. (2010). The relationship between obsessive beliefs and symptom dimensions in obsessive-compulsive disorder. Behaviour Research and Therapy, 48(10), 949–954. Wu, K. D., & Cortesi, G. T. (2009). Relations between perfectionism and obsessive-compulsive symptoms: Examination of specificity among the dimensions. Journal of Anxiety Disorders, 23(3), 393–400. Yorulmaz, O., Karanci, A. N., & Tekok-Kiliç, A. (2006). What are the roles of perfectionism and responsibility in checking and cleaning compulsions? Journal of Anxiety Disorders, 20, 312–327.

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