A meta-analysis of disordered eating and its association with self-criticism and self-compassion

OBJECTIVE

Future treatments for eating disorders (ED) need to be enhanced by targeting maintaining mechanisms. Literature suggests self-criticism and self-critical perfectionism act as key mechanisms exacerbating ED, and self-compassion protects against self-criticism. This meta-analysis examines associations between self-criticism and self-critical perfectionism on disordered eating (DE), and reviews how self-compassion and self-criticism relate to each other with respect to DE.

METHOD

Searches across three databases yielded 135 studies across 42,952 participants. Heterogeneity, publication bias, and quality assessments were analyzed. Moderation analyses between self-criticism measures, self-compassion measures, between clinical and nonclinical samples, and between cross-sectional and experimental studies were also conducted.

RESULTS

Random-effects models showed a medium positive link between self-criticism and DE (r = .37), and 10 subgroups pertaining to various measures of self-criticism utilized in literature showed small to large positive links with DE (r = .20-.52). Preliminary evidence also suggests negative relationships between self-compassion and DE (r = -.40 to -.43) and negative relationships between self-compassion and self-criticism (r = -.04 to -.88).

DISCUSSION

Greater levels of self-criticism is linked with greater levels of DE and reduced levels of self-compassion, suggesting a need to tackle self-criticism and nurture self-compassion in standard treatments for ED. Understanding these interactions better in conjunction with dismantling intervention studies can help develop more effective and efficient interventions targeting self-criticism and self-compassion for people with DE.

PUBLIC SIGNIFICANCE STATEMENT

Higher levels of self-criticism are linked with higher levels of DE and lower self-compassion. Self-compassion interventions could be more effective and efficient in reducing ED symptoms if self-criticism is tackled early in such treatments.

Perfectionism as a predictor of change in digital self-guided interventions for public speaking anxiety in adolescents: A secondary analysis of a four-armed randomized controlled trial

Public Speaking Anxiety (PSA) interventions targeting adolescents exist; however, not all gain improvement. This exploratory study investigated whether PSA interventions resulted in a decrease in perfectionism and whether pre-treatment level and changes in perfectionism moderated the effects on PSA and social anxiety. The sample consisted of 100 adolescents from junior high schools randomized to four groups: 1) VR only (n = 20), 2) VR + online exposure program (n = 20), 3) online psychoeducation and online exposure program (n = 40), 4) waitlist and online psychoeducation program (n = 20). Self-reported symptoms of PSA, social anxiety, and perfectionism were measured at pre, week 3, post, and 3-months follow-up. Level and change in outcome variables were analyzed using latent growth curve modeling. Results revealed that the interventions did not lead to a reduction in perfectionism. Reduction in perfectionism was associated with a larger reduction in all outcome measures from post to follow-up. No interaction was found between pre-treatment perfectionism and PSA symptoms. High pre-treatment levels of perfectionism were associated with poorer outcomes on social anxiety symptoms from post to follow-up for online exposure groups. The results indicate that one should assess and address high pre-treatment levels of perfectionism during PSA interventions.

The effectiveness of short-term dynamic/interpersonal group therapy on perfectionism; assessment of anxiety, depression and interpersonal problems

Perfectionism is acknowledged as a core vulnerability and a perpetuating factor in several psychopathologies. The purpose of the present study was to investigate the effectiveness of short-term psychodynamic/interpersonal group psychotherapy for perfectionism and perfectionism-related distress such as anxiety, depression, and interpersonal problems. This study is a quasi-experimental study applying clinical trial method and contains pre-test, post-test, follow-up periods and control group. The study population included students and the sample consisted of 30 people with extreme perfectionism, who were assigned in two groups of 15 people, experimental and waiting list groups using randomized block design. Research instruments included Tehran Multidimensional Perfectionism Scale, Perfectionistic Self Presentation Scale, Perfectionistic Cognition Inventory, Beck Depression Inventory-II, Beck Anxiety Inventory and Inventory of Interpersonal Problems-32. In order to analyse the collected data, mixed analysis of variance and Repeated Measures Analysis of Variance were used in SPSS software version 22. The results show that the intervention in the experimental group compared to the waiting list group caused a clinically and statistically significant decrease in the mean scores. This result is observable and evident in all levels of perfectionism and psychological distress (anxiety, depression and interpersonal problems), except for the subscale of Non-Display of Imperfection from the Perfectionistic Self Presentation Scale. These results were preserved through the follow-up periods. These results show that short-term dynamic/interpersonal group therapy is effective in treating most of the components of perfectionism and concerning its effectiveness; it reduced psychological distress and showed that the components pertaining to perfectionism are factors of vulnerability in this regard.

Computerized treatment of perfectionism through mistake making: A preliminary study

BACKGROUND AND OBJECTIVES

Perfectionism has important implications for self-worth, personal standards, and psychopathology. The aim of this study was to test the efficacy of a novel two-week, computerized, exposure-based treatment for perfectionism (ETP).

METHODS

Seventy-one university students with elevated perfectionism were randomized to either the ETP group (n = 36) or the waitlist (WL) control group (n = 35). The ETP group was asked to complete the intervention at home, every three days for two weeks for a total of five treatment sessions. The tasks in the ETP condition were engineered to have participants repeatedly make mistakes. All participants returned two weeks after the baseline visit for a post-treatment assessment.

RESULTS

Compared to WL, ETP led to lower overall perfectionism, concern over mistakes, personal standards, depressive symptoms, social anxiety symptoms, and error sensitivity at post-treatment. No effects of treatment were found on trait anxiety, obsessive-compulsive symptoms, or eating disorder symptoms.

LIMITATIONS

Participants were university students of similar age and education level, which restricts generalizability. Additionally, the study relied on a waitlist control condition.

CONCLUSIONS

This study provided preliminary evidence for a novel online intervention for perfectionism.

Online computer or therapist-guided cognitive behavioral therapy in university students with anxiety and/or depression: study protocol of a randomised controlled trial

INTRODUCTION

Emerging adulthood is a phase in life that is associated with an increased risk to develop a variety of mental health disorders including anxiety and depression. However, less than 25% of university students receive professional help for their mental health reports. Internet-based cognitive behavioural therapy (iCBT) may entail useful interventions in a format that is attractive for university students. The aim of this study protocol is to test the effectiveness of a therapist-guided versus a computer-guided transdiagnostic iCBT programme with a main focus on anxiety and depression.

METHODS AND ANALYSIS

University students with anxiety and/or depressive symptoms will be randomised to a (1) 7-week iCBT programme (excluding booster session) with therapist feedback, (2) the identical iCBT programme with computer feedback only or (3) care as usual. Participants in the care as usual condition are informed and referred to conventional care services and encouraged to seek the help they need. Primary outcome variables are self-reported levels of anxiety as measured with the General Anxiety Disorder-7 and self-reported levels of depression as measured with the Patient Health Questionnaire-9. Secondary outcomes include treatment adherence, client satisfaction, medical service use, substance use, quality of life and academic achievement. Assessments will take place at baseline (t1), midtreatment (t2), post-treatment (t3), at 6 months (t4) and 12 months (t5) postbaseline. Social anxiety and perfectionism are included as potentially important predictors of treatment outcome. Power calculations are based on a 3 (group) × 3 (measurement: pretreatment, midtreatment and post-treatment) interaction, resulting in an aimed sample of 276 participants. Data will be analysed based on intention-to-treat and per protocol samples using mixed linear models.

ETHICS AND DISSEMINATION

The current study was approved by the Medical Ethics Review Committee (METC) of the Academic Medical Centre, Amsterdam, The Netherlands (number: NL64929.018.18). Results of this trial will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NL7328.

Reformulated Object Relations Theory: A Bridge Between Clinical Psychoanalysis, Psychotherapy Integration, and the Understanding and Treatment of Suicidal Depression

In contrast to the fruitful relationship between psychoanalysis/psychoanalysts and the humanities, institutionalized psychoanalysis has been largely resistant to the integration of psychoanalysis with other empirical branches of knowledge (infant observation, psychotherapy research, psychological and neurobiological sciences), as well as clinical ones [primarily cognitive-behavioral therapy (CBT)]. Drawing from two decades of theoretical and empirical work on psychopathology, psychotherapy, and psychoanalysis, the author aims to show how a reformulation of object relations theory (RORT) using (neuro-)psychological science may enhance a clinical-psychoanalytic understanding and treatment of suicidal depression, which constitutes one of the most formidable health challenges of our time. Specifically, he rewrote the notion of Melanie Klein positions-primarily the depressive position-using extant knowledge of structure of emotions, the centrality of mental representations of the future ("prospection") and the toxic nature of criticism-based emotions. This reformulation enables a dialog between clinical psychoanalysis and other therapeutic schools of thought and sheds light on the understanding and treatment of suicidal depression.

Patient perfectionism and clinician impression formation during an initial interview

OBJECTIVES

The negative impact of pre-treatment patient perfectionism on therapeutic alliance and outcomes has been well documented. However, there is much to learn about how patient perfectionism impacts the development of the therapeutic alliance. Our study addressed this by examining the extent to which trait and self-presentational components of perfectionism influence clinician's perceptions of patients during an initial interview.

DESIGN

In a re-analysis of data from Hewitt et al., 2008, Psychiatry, 71, 93-122, participants were 90 treatment-seeking adults (aged 19-64, M_age  = 36.2; 40 men) recruited from outpatient mental health clinics. Each patient had a one-on-one, semi-structured interview with a clinician that lasted approximately 50 min.

METHOD

Patients completed self-report measures assessing trait perfectionism, perfectionistic self-presentation, and symptom distress before the interview. Patients were then invited to discuss reasons for seeking treatment and to reflect on the two most challenging situations in their lives in which they had not coped well. Following the interview, clinicians indicated their overall impressions of patients by responding to three self-report questions and rated patients' distress and hostility via nine adjectives.

RESULTS

After controlling for patients' symptom distress, other-oriented perfectionism and non-display of imperfection had small positive relationships with clinician-rated hostility; self-oriented perfectionism, socially prescribed perfectionism, and non-disclosure of imperfection had small-to-moderate negative relationships with clinician impressions. Additionally, path analysis revealed other-oriented perfectionism and non-display of imperfection indirectly predicted less favourable clinician impressions through clinician-rated hostility.

CONCLUSIONS

Findings highlight the importance of evaluating and addressing trait and self-presentation components of perfectionism early in the therapeutic process.

PRACTITIONER POINTS

Higher levels of other-oriented perfectionism and non-display of imperfection were associated with greater clinician-rated hostility during an initial interview. Patient hostility mediated the relationship between patients' other-oriented perfectionism, non-display of imperfection, and less favourable clinician impressions. Our study highlights the importance of assessing and attending to patient perfectionism and displays of hostility during the earliest stages of therapeutic contact.

The comparison between CBT focused on perfectionism and CBT focused on emotion regulation for individuals with depression and anxiety disorders and dysfunctional perfectionism: a randomized controlled trial

BACKGROUND

There is considerable evidence indicating that similar aetiological and maintenance processes underlie depressive and anxious psychopathology. According to the literature, perfectionism and emotion regulation are two transdiagnostic constructs associated with symptoms of emotional disorders.

AIMS

This study is the first randomized controlled trial comparing the efficacy of cognitive behavioural therapy for perfectionism (CBT-P) and the unified protocol for the transdiagnostic treatment of emotional disorders (UP).

METHOD

Seventy-five participants with a range of depressive and anxiety disorders and elevated perfectionism were randomized to three conditions: CBT-P, UP or a waitlist control (WL).

RESULTS

Repeated measures ANOVA indicated that the treatment groups reported a significantly greater pre-post reduction in the severity of symptoms of disorders, as well as a significantly greater pre-post increase in quality of life, all with moderate to large effect sizes compared with the WL group. Treatment gains were maintained at 6-month follow-up. The CBT-P group reported a significantly greater pre-post reduction in perfectionism compared with UP, and the UP group reported a significantly greater pre-post improvement in emotion regulation compared with CBT-P.

CONCLUSIONS

Findings support CBT for perfectionism and regard UP as efficacious treatments for individuals with depression and anxiety disorders who also have dysfunctional perfectionism. It appears that perfectionism cannot be a serious obstacle to UP. As this is a preliminary study and has some limitations, it is recommended that further research be conducted.

Perfectionistic traits and self-presentation are associated with negative attitudes and concerns about seeking professional psychological help

Numerous factors influence whether an individual is able and willing to seek professional help for psychological difficulties. One of these may be perfectionism, a multidimensional personality construct that has been linked to poor psychological adjustment. The current study investigated whether perfectionism traits and self-presentational facets were associated with negative help-seeking attitudes and concerns about psychotherapy. Samples of university (N = 299) and community (N = 77) men and women completed the Multidimensional Perfectionism Scale, Perfectionistic Self-Presentation Scale, Attitudes Towards Seeking Professional Help Scale, and Thoughts About Psychotherapy Survey. Various components of perfectionism were associated with both negative help-seeking attitudes and concerns about psychotherapy. The findings suggest that perfectionistic behaviour may be an important dispositional factor that interferes with seeking and obtaining help for psychological difficulties. Theoretical and clinical implications are discussed.

Self-criticism and psychotherapy outcome: A systematic review and meta-analysis

Self-criticism involves constant and harsh self-scrutiny, overly critical evaluations of one's own behavior, and negative reactions to perceived failures in terms of active self-bashing. Self-criticism is associated with various mental disorders and psychotherapy outcome. This paper provides (1) a meta-analysis of the association between pre-treatment self-criticism and multiple treatment outcomes, and (2) a systematic review of the association between change in self-criticism and therapy outcome. Based on a systematic literature search, 49 longitudinal studies (56 independent effect sizes; 3277 patients) were included in the meta-analysis and 7 studies were identified for the additional systematic review. A random-effects meta-analysis was performed to assess the magnitude of the association between self-criticism and outcome, also considering potential moderators. The overall association between pre-treatment self-criticism and psychotherapy outcome was r = -.20 (95% CI = -.25 - -.16, p < .0001), suggesting that higher levels of self-criticism are related to poorer outcome. Although effect sizes showed little heterogeneity, the association varied by type of mental health problem and indicated stronger associations with certain disorders (e.g., eating disorders). The review based on change scores yielded inconsistent results. Our findings support the relevance of self-criticism for psychotherapy outcome.

Patient Extratherapeutic Interpersonal Problems and Response to Psychotherapy for Depression

OBJECTIVES

This paper aimed to synthesize empirical findings of patient extratherapeutic interpersonal variables associated with individual psychotherapy treatment outcomes in adult outpatients with depression.

METHODS

A systematic search strategy was used to identify relevant studies. Thematic analysis was used to identify recurring themes in the findings.

RESULTS

Forty studies met search criteria. Three themes of patient extratherapeutic interpersonal variables were identified: capacity to engage with others, capacity to navigate relationships, and capacity to achieve intimacy, progressing from basic to advanced levels of interpersonal interaction. Interpersonal variables such as interpersonal distress and style, attachment orientation, and quality of object relations were particularly useful in predicting treatment outcomes, whereas access to social support and marital status provided mixed results, likely because they do not account for relationship quality.

CONCLUSIONS

Recognizing variables associated with treatment response can help clinicians identify patients at risk for nonresponse and guide efforts for adapting existing therapies and developing new ones.

The Preteen Perfectionist: An Evaluation of the Perfectionism Social Disconnection Model

This research investigated associations between socially prescribed and self-orientated perfectionism, and the social functioning of 510 preteens (M_age = 11.2). The study focused on predictions from the Perfectionism Social Disconnection Model (PSDM) by determining whether rejection sensitivity and social isolation, in that sequence, mediated the associations between both perfectionism types and mental health outcomes. Employing both survey and experimental methods, findings indicated that both types of perfectionism in preadolescence were associated with increased interpersonal difficulty, rejection sensitivity and feelings of social isolation, as well as higher levels of eating disorder symptoms, depression, and anxiety. Results from serial mediation analyses found general support for the theoretical predictions of the PSDM for socially prescribed perfectionism, and extending upon previous research, for self-orientated perfectionism. The age of the sample suggests that both forms of perfectionism may be important targets in programs to prevent the development of mental health problems.

Self-compassion moderates the perfectionism and depression link in both adolescence and adulthood

Background

Psychological practitioners often seek to directly change the form or frequency of clients’ maladaptive perfectionist thoughts, because such thoughts predict future depression. Indirect strategies, such as self-compassion interventions, that seek to change clients’ relationships to difficult thoughts, rather than trying to change the thoughts directly could be just as effective. This study aimed to investigate whether self-compassion moderated, or weakened, the relationship between high perfectionism and high depression symptoms in both adolescence and adulthood.

Methods

The present study utilised anonymous self-report questionnaires to assess maladaptive perfectionism, depression, and self-compassion across two samples covering much of the lifespan. Questionnaires were administered in a high school setting for the adolescent sample (Study 1, M_age = 14.1 years, n = 541), and advertised through university and widely online to attract a convenience sample of adults (Study 2, M_age = 25.22 years, n = 515).

Results

Moderation analyses revealed that self-compassion reduced the strength of relationship between maladaptive perfectionism and depression in our adolescent Study 1 (β = -.15, p < .001, R² = .021.) and our adult study 2 (β = -.14, p < .001, R² = .020).

Limitations

Cross-sectional self-reported data restricts the application of causal conclusions and also relies on accurate self-awareness and willingness to respond to questionnaire openly.

Conclusions

The replication of this finding in two samples and across different age-appropriate measures suggests that self-compassion does moderate the link between perfectionism and depression. Self-compassion interventions may be a useful way to undermine the effects of maladaptive perfectionism, but future experimental or intervention research is needed to fully assess this important possibility.

Adolescent perfectionism: Structural features of the Frost Multidimensional Perfectionism Scale and correlates with attachment and psychopathology

OBJECTIVES

Perfectionism is recognized as a significant risk factor for psychopathology. Emerging research links attachment to perfectionism in adult and college-age samples. The Frost Multidimensional Perfectionism Scale (FMPS) has been used in adults and adolescents with a variety of factor structures found. This study sought to establish the factor structure in a general adolescent sample prior to testing for associations between perfectionism, attachment, and psychopathology in the same sample.

DESIGN

A cross-sectional survey design was used. Confirmatory factor analysis, and correlational and regression analyses were employed.

METHODS

A total of 290 adolescents, aged 12-18 years, were recruited from a state secondary school. All completed the FMPS along with brief measures of attachment and psychopathology.

RESULT

Exploratory and confirmatory factor analyses failed to replicate previously published models, and a new six-item, 1-factor model representing perfectionism was found instead. This new variable was then used to establish a role for perfectionism and attachment anxiety in predicting internalizing problems. Perfectionism also correlated with conduct problems and hyperactivity.

CONCLUSION

This study established a novel factor structure for the FMPS, allowing proof of principle of the role of perfectionism in a relationship with attachment and psychopathology, which after replication, may inform new interventions for perfectionism. Caution is noted about the use of extant perfectionism measures that are not properly developmentally informed and which do not capture the dynamic nature of adolescence and adolescent perfectionism.

PRACTITIONER POINTS

Perfectionism is a feature of adolescent psychopathology, including internalizing and externalizing problems. Perfectionism is associated with attachment anxiety and together contributes to internalizing problems. Current conceptualizations of perfectionism may not capture the specific developmental and dynamic aspects of adolescence and should not be regarded as a stable personality trait.

Are Perfectionist Therapists Perfect? The Relationship between Therapist Perfectionism and Client Outcomes in Cognitive Behavioural Therapy

Background: The psychological literature suggests that therapist perfectionism is common and potentially detrimental to client recovery. Little is known about the relationship between therapist perfectionism and client outcomes. Aims: This study aimed to measure perfectionism in High Intensity Cognitive Behavioural therapists, and establish any relationships between dimensions of therapist perfectionism, client outcomes and drop-out rates in treatment. Method: Thirty-six therapists took part in the study; levels of perfectionism were measured using a self-report questionnaire and these were analysed in relation to the clinical outcomes from a sample of their clients. Results: The results indicated that therapist perfectionism may be less common than previously suggested. Overall, a number of significant negative associations were observed between aspects of therapist perfectionism (e.g. having high standards for others), treatment efficacy and client retention in treatment. Conclusions: Therapist perfectionism is associated with CBT treatment outcomes; tentative recommendations for therapists managing their own schema as part of their clinical practice have been made, although further investigation is required.

Mechanisms of change in psychotherapy for depression: An empirical update and evaluation of research aimed at identifying psychological mediators

We present a systematic empirical update and critical evaluation of the current status of research aimed at identifying a variety of psychological mediators in various forms of psychotherapy for depression. We summarize study characteristics and results of 35 relevant studies, and discuss the extent to which these studies meet several important requirements for mechanism research. Our review indicates that in spite of increased attention for the topic, advances in theoretical consensus about necessities for mechanism research, and sophistication of study designs, research in this field is still heterogeneous and unsatisfactory in methodological respect. Probably the biggest challenge in the field is demonstrating the causal relation between change in the mediator and change in depressive symptoms. The field would benefit from a further refinement of research methods to identify processes of therapeutic change. Recommendations for future research are discussed. However, even in the most optimal research designs, explaining psychotherapeutic change remains a challenge. Psychotherapy is a multi-dimensional phenomenon that might work through interplay of multiple mechanisms at several levels. As a result, it might be too complex to be explained in relatively simple causal models of psychological change.

The Impeding Role of Self-Critical Perfectionism on Therapeutic Alliance During Treatment and Eating Disorder Symptoms at Follow-up in Patients with an Eating Disorder

This study examines the impeding role of self-critical perfectionism at onset of treatment on therapeutic alliance during treatment and eating disorder symptoms at follow-up in patients with an eating disorder. Participants were 53 female patients with a mean age of 21.1 years treated for an eating disorder in a specialized inpatient treatment unit. Self-critical perfectionism was assessed at admission, therapeutic alliance was assessed during treatment (after three months of treatment), and eating disorder symptoms were assessed at admission, after three months and one year later. Self-critical perfectionism negatively related to treatment alliance with the therapist. Although self-critical perfectionism was not directly predictive of subsequent changes in eating disorder symptoms, it was indirectly related to less reduction in body dissatisfaction through the therapeutic alliance. These results point to the importance of self-critical perfectionism in the therapeutic alliance and in changes in body image problems. Treatment implications are discussed.

Perfectionistic Concerns, Social Negativity, and Subjective Well-Being: A Test of the Social Disconnection Model

Partner-specific perfectionistic concerns (PC) include concern over mistakes, self-criticism, and socially prescribed perfectionism as it pertains to one's partner. The social disconnection model proposes that PC influences well-being indirectly through interpersonal problems. Thus, we hypothesized that social negativity (expressed anger, hostility, and rejection) would mediate the relationship between dyadic PC and subjective well-being. Data from 203 romantic dyads (92.1% heterosexual) were collected using self-report surveys and a four-wave, 4-week longitudinal design. Participants were predominantly female (53.1%), young (M = 22.69 years), and Caucasian (82.3%). Data were analyzed using an actor-partner interdependence model with multilevel structural equation modeling. There were significant actor effects at the between-subjects and within-subjects levels, and significant partner effects for the relationship between PC and social negativity at the within-subject level. Social negativity mediated the relationships between PC and both negative affect and life satisfaction. However, positive affect was more weakly related to PC and social negativity. The social disconnection model was supported. PC was positively associated with one's own social negativity and evoked hostile behaviors from one's partner. Hostile, rejecting behaviors reduced the well-being of the actor, but not the partner. Results suggest perfectionism may be best understood within an interpersonal context.

Reliability, Sensitivity, and Specificity of Case Formulations for Comorbid Profiles in Interpersonal Reconstructive Therapy: Addressing Mechanisms of Psychopathology

Interpersonal Reconstructive Therapy (IRT) case formulations describe psychosocial mechanisms of affective and personality pathology in ways that enhance the effectiveness of psychotherapy for individuals. With a valid and reliable IRT case formulation, a clinician is in a better position to draw upon effective techniques to maximize treatment effects. The case formulation and treatment models for IRT were described in depth along with the IRT treatment model by Benjamin (2003/2006). Data in this report from 93 adult inpatients with complex and comorbid presentations suggest that the case formulation is highly reliable and unique to individuals, and that symptoms reflect current interpersonal stresses linked to early interactions involving forms of hostility in relation with attachment figures and corresponding to three basic patterns in adulthood: identification (be like him or her), recapitulation (act as you did with him or her), and introjection (treat yourself as you were treated).

Impact of environmental and personality factors upon adolescents before and after psychotherapeutic intervention

It is important to understand the risk factors and resilience factors that contribute to psychological distress or to a sense of well-being in adolescents. This study focuses on life events and social support from an external-environmental aspect. The focus from an internal-personality aspect is on self-criticism and self-disclosure. In this study, 155 adolescents, ages 12-18 years, were divided into two groups. The experimental group included 70 adolescents requesting psychotherapy for emotional disorders. The control group included 85 adolescents without emotional disorders. Participants in the experimental group were followed up to the completion of six months of psychotherapy. Adolescents in the experimental group had undergone more negative life events and a significantly smaller number of positive life events compared to the control group [F(4, 143)=9.77, p<0.001, Eta(2)=.22]. The experimental group was characterized by a diminished degree of social support compared to the control group [F(2, 144)=7.27, p<0.01, Eta(2)=.09]. Regarding self-criticism and self-disclosure, no differences were found between the control and experimental groups [F(3, 148)=2.18, p>0.05, Eta(2)=.04]. The prospective analysis following six months of psychotherapy indicated a significant improvement in distress variables reported by the parents but not by the subjects themselves, pointing to the importance of family intervention as part of adolescent psychotherapy. A decrease in the level of self-criticism after psychotherapeutic intervention was found [F(1, 18)=4.41, p<0.05, Eta(2)=.20], altering self-criticism from a factor that needs to be neutralized to a factor that can be improved during psychotherapy.

Do PTSD symptoms and trauma-related cognitions about the self constitute a vicious cycle? Evidence for both cognitive vulnerability and scarring models

Cognitive models of post-traumatic stress disorder (PTSD) posit that negative cognitions regarding the self and the world underlie the disorder. In contrast, scarring models - which postulate that distress brings about an elevation in vulnerability - predict the inverse relationship. Both models were tested amongst 156 Israeli trauma victims. Participants were assessed for PTSD symptoms and trauma-related cognitions (negative thoughts regarding self and world) over 2 weeks (T1), 4 weeks (T2), and 12 weeks (T3) following the traumatic event. A cross-lagged structural equation modeling analysis yielded evidence for both cognitive vulnerability and scarring. Baseline PTSD was prospectively associated with an increase in negative cognitions regarding both the self and the world during the T1-T2 period. Negative cognitions regarding the self were prospectively associated with an increase in PTSD symptoms during both T1-T2 and T2-T3 periods. PTSD symptoms and negative cognitions regarding the self thus appear to form a vicious cognitive-symptomatic cycle which might impede recovery.

Web-based cognitive-behavioral therapy for perfectionism: a randomized controlled trial

This study assessed the effectiveness of a web-based cognitive behavioral intervention (CBT) in reducing perfectionism and psychological distress in post-secondary students. Participants assessed as high in perfectionism (n=77) were randomized to one of three 10-week, web-based, intervention conditions (no treatment [NT], general stress management [GSM], or CBT). Results indicated the CBT condition was effective in reducing perfectionism, and supported a pattern of significantly greater improvement than observed in participants in the GSM or NT conditions. While both CBT and GSM demonstrated capacities to significantly reduce distress, for CBT participants changes in perfectionism were significantly correlated with changes in depression and anxiety. Results offer support for the effectiveness of web-based CBT in positively affecting perfectionist-related problems. Given the considerable proportion of individuals who suffer from perfectionism-related distress, the intervention's apparent effectiveness, cost-effectiveness and ease of dissemination warrant future replication studies.

Social support modifies the relationship between personality and depressive symptoms in older adults

OBJECTIVE

To explore the relationship between personality, social support, and depression in older adults, identify the personality trait and social support dimension most closely associated with depression, and determine whether the relationship between personality and depression varies by level of social support.

DESIGN

Cross-sectional analysis within longitudinal study.

PARTICIPANTS

Older patients originally diagnosed with major depression (n = 108) and never-depressed comparison group of older adults (n = 103).

MEASUREMENTS

Patients sufficiently recovered from major depression and comparison participants were administered the NEO Personality Inventory. Social support was measured annually for both groups. Patients were administered the Montgomery-Asberg Depression Rating Scale (MADRS) every 3 months.

RESULTS

Patients and comparison participants differed on four of the five NEO domains and all four social support dimensions, but personality did not significantly predict depression status (patient/comparison) in controlled analyses. Within the patient group, subjective social support was the only dimension correlated with MADRS score. In separate linear regression analyses among the patients, controlling for age, sex, and subjective social support, the domains of Neuroticism, Openness to Experience, Conscientiousness, and Extraversion were associated with MADRS score. For Neuroticism and Openness, the association varied by level of subjective social support.

CONCLUSIONS

Our research confirmed that older patients differed from never-depressed older adults in dimensions of personality and social support, and the relationship between these variables differed by depression status. The relationship between personality, social support, and depressive symptoms in older adults recovering from depression is also complex, with subjective social support modifying the association between personality and depression.

Offering support to suicidal individuals in an online support group

The objective of this study was to reveal response strategies to suicidal messages and to examine the relationships between the messages and types of responses in an online support group moderated by volunteers within an interpersonal perspective of the Action Theory. This theory posits that individuals actively impact their social environment, which in turn shapes their development and mental health. In the study, 120 interactions were analyzed to identify characteristics of the message and strategies of response. The analysis yielded 8 strategies employed by the volunteers in response to the suicidal messages. Hypothesized relationships between those strategies and characteristics of suicidal messages were found. The results suggest that online support groups enable suicidal individuals to generate an environment that provides emotional support, and offer alternatives to the suicidal view.

Longitudinal associations between post-traumatic distress and depressive symptoms following a traumatic event: a test of three models

BACKGROUND

Symptoms of post-traumatic stress disorder (PTSD) and depression are highly co-morbid following a traumatic event. Nevertheless, decisive evidence regarding the direction of the relationship between these clinical entities is missing.

METHOD

The aim of the present study was to examine the nature of this relationship by comparing a synchronous change model (PTSD and depression are time synchronous, possibly stemming from a third common factor) with a demoralization model (i.e. PTSD symptoms causing depression) and a depressogenic model (i.e. depressive symptoms causing PTSD symptoms). Israeli adult victims of single-event traumas (n=156) were assessed on measures of PTSD and depression at 2, 4 and 12 weeks post-event.

RESULTS

A cross-lagged structural equation modeling (SEM) analysis provided results consistent with the synchronous change model and the depressogenic model.

CONCLUSIONS

Depressive symptoms may play an important role in the development of post-traumatic symptoms.

Patient personality and outcome in short-term psychodynamic psychotherapy

The current study examines pretherapy patient personality characteristics that may be related to outcome in Short-Term Psychodynamic Psychotherapy. The prognostic ability of the Capacity for Dynamic Process Scale (CDPS; Thackrey et al., A Collection of Psychological Scales. 1993:57-63) was examined in a sample of 71 outpatient adults seeking treatment at a university-based community clinic. The relationship of CDPS to various outcome variables, including both patient and clinician perspectives, were investigated. A Principal Components Factor Analysis of the items comprising the CDPS was used to identify salient item clusters representing the insight, affective, or relational capacities of patients. Results indicated that the CDPS Total score was positively correlated to several of the outcome measures, but not at a level of significance. Certain CDPS items, and to a greater extent items composing the Insight subscale, demonstrated significant positive relationships to a number of patient and clinician rated outcome measures. Results from the study will be discussed in regard to their applied clinical implications.

The role of personality in psychotherapy for anxiety and depression

A trait approach to personality has many implications for psychotherapy. Given that traits contribute to the expression of symptoms of common psychiatric disorders, are moderately heritable, and relatively stable (yet also dynamic to some extent), long-term change in symptoms is possible but is likely to be limited. Analogous to the manner in which genes set the reaction range for phenotype, standing on certain traits may set the patient's "therapeutic range." On the other hand, some of the same traits that may limit the depth of therapeutic benefits might also increase their breadth. In addition, taking the patient's standing on different traits into account can inform the choice of therapeutic strategy and targets and can affect the formation of the therapeutic alliance and compliance with self-help exercises. Finally, other aspects of personality beyond traits, such as ego development and narrative identity, also appear to have important implications for psychotherapy.

Self-criticism versus neuroticism in predicting depression and psychosocial impairment for 4 years in a clinical sample

The present study extended previous findings demonstrating self-criticism, assessed by the Dysfunctional Attitude Scale (DAS) (Weissman AN, Beck AT. Development and validation of the Dysfunctional Attitude Scale: a preliminary investigation. Paper presented at the 86th Annual Convention of the American Psychological Association, Toronto, Ontario, Canada, 1978), as a potentially important prospective predictor of depressive symptoms and psychosocial functional impairment over time. Using data from a prospective, 4-year study of a clinical sample, DAS self-criticism and neuroticism were associated with self-report depressive symptoms, interviewer-rated major depression, and global domains of psychosocial functional impairment 4 years later. Hierarchical multiple regression results indicated that self-criticism uniquely predicted depressive symptoms, major depression, and global psychosocial impairment 4 years later over and above the Time 1 assessments of these outcomes and neuroticism. In contrast, neuroticism was a unique predictor of self-report depressive symptoms only 4 years later. Path analyses were used to test a preliminary 3-wave mediational model and demonstrated that negative perceptions of social support at 3 years mediated the relation between self-criticism and depression/global psychosocial impairment for 4 years.

Suicide prevention by online support groups: an action theory-based model of emotional first aid

In the last two decades, online support groups have become a valuable source of help for individuals in suicidal crisis. Their attractiveness is attributed to features that enhance help-seeking and self-disclosure such as availability, anonymity, and use of written communication. However, online support groups also suffer from limitations and potential risks as agents of suicide prevention. The Israeli Association for Emotional First Aid (ERAN) has developed a practical model that seeks to maximize the benefits and minimize the risks of online suicide prevention. The model applies the Action Theory concepts whereby individuals shape their own environment. The present paper presents the model, which is based on an online support group combined with personal chat and a telephonic help line. The online support group is moderated by paraprofessionals who function as both process regulators and support providers. The principles and practice of the model are described, the theoretical rationale is presented, and directions for future research are suggested.

Patients' self-criticism is a stronger predictor of physician's evaluation of prognosis than pain diagnosis or severity in chronic pain patients

The experience of pain is influenced by patients' personality, social and cultural background, and patient-doctor interaction. This study examines the role of self-reported pain, pain diagnosis, age, gender, depression, and the personality trait of self-criticism (defined as individuals' tendency to set unrealistically high self-standards and to adopt a punitive stance toward one's self), in determining physicians' view of expected prognosis in response to chronic pain management. Before the first visit to a tertiary chronic pain clinic, patients provided information regarding their perceived pain, depression, and self-criticism. Immediately subsequent to the visit, physicians' evaluated expected prognosis. Participating physicians were blinded to the patient's psychosocial variables collected. Sixty-four patients with chronic pain (34 women and 30 men) with various diagnoses were included. Patients' age, gender, pain diagnosis, self-reported pain, and depression did not significantly correlate with physician's estimation of expected prognosis. In contrast, patients' self-criticism emerged as an independent predictor of physicians' pessimism regarding outcome. Thus, in the chronic pain clinic setting, patients' personality, rather than self-reported pain experience, determines doctor's clinical judgment of expected prognosis.

PERSPECTIVE

Chronic pain is a multimodal negative experience that is determined by physiological, cognitive, personological, and interpersonal factors. In line with this observation, we found patients' personality, specifically, their self-criticism, determines physicians' clinical judgment of expected prognosis.