1. An internet-delivered cognitive-behavioral program for perfectionism
Authors:
Adina Flueraș, Oana Nădăban, Domelia Moga, Silvia Măgurean, Bogdan Tulbure
West University of Timișoara

2. Perfectionism
A tendency to set high standards for performance coupled with a hypercritical attitude when the standards are not met
(Stoeber & Janssen, 2011)

3. Perfectionism Maldaptive form Adaptive form
Positively associated with emotional distress and psychopathology
(Limburg, Watson, Hagger & Eagan, 2016, Lo & Abbott, 2013)
Adaptive form
Positively associated with achievement
(Stoeber & Otto, 2006)

4. Transdiagnostic process?
A clinical review by Egan, Wade, & Shafran (2011) – highlights perfectionism as transdiagnostic process:
The clinical review identified high levels of perfectionism across several disorders: eating disorders, anxiety disorders, depression, obsessive compulsive personality disorder
Perfectionism interferes with treatment outcome
Other evidence come from the results – effects of interventions addressing perfectionism. What happens after we address perfectionism in intervention programs? What happens to perfectionism and what happenes to other clinical associated symptoms?
Perfectionism interferes with treatment outcome through:
Poorer therapeutic alliance
Lower quality of social network
Higher drop-out in some cases

5. Interventions addressing perfectionism
Meta-analysis by Lloyd, Schmidt, Khondoker, & Tchanturia (2015)
8 studies with interventions on perfectionism
Interventions significantly decrease perfectionism levels
Medium effect on anxiety and depression
If perfectionism is a transdiagnostic process, after we address it in interventions, we expect other clinical symptoms to improve as a consequence of decreases in perfectionism – let go of perfectionism and live  So is it truly so?
Few studies argued for the transdiagnostic effect by including measures of other psychological symptoms (except for anxiety and depression)
Most of the interventions are face to face

6. An internet-delivered program for perfectionism
THE ALMOST PERFECT PROGRAM
OBJECTIVES
1. Analyze the efficacy of an internet- delivered program for perfectionism in a Romanian non-clinical sample
2. Provide further evidence for the transdiagnostic nature of perfectionism by analyzing the effects of the intervention on perfectionism as well as other clinical outcomes
Fursland, Raykos, & Steele (2009) - available through the Centre for Clinical Interventions, Western Australia.
9 MODULES (of 5 days each = 45 days total program):
(1) What is perfectionism?
(2) Understanding perfectionism
(3) What Keeps Perfectionism Going?
(4) Changing perfectionism
(5) Reducing my perfectionist behavior
(6) Challenging my perfectionist thinking
(7) Adjusting unhelpful rules and assumptions
(8) Re-evaluating the importance of achieving
(9) Putting it all together.

7. Participants Eligibility: * age over 18 years
* elevated levels of perfectionism (i.e., scores > 36 on the High Standards subscale of the Almost Perfect Scale-Revised (Slaney, Rice, Mobley, Trippi, & Ashby, 2001), and/or an overall score > 84 on the Frost Multidimensional Perfectionism Scale (Frost, Marten, Lahart, & Rosenblate, 1990)
* low to moderate levels of depression (scores < 29 for the Beck Depression Inventory–II, BDI-II; Beck, Steer, & Brown, 1996), anxiety (scores < 35 for the Beck Anxiety Inventory, BAI; Beck, Epstein, Brown, & Steer, 1988), and obsessive-compulsive symptoms (scores < 23 for the Yale-Brown Obsessive Compulsive Scale, Y-BOCS; Goodman et al., 1989)
* no other psychological/psychiatric treatment,
* no suicidal ideation (scores < 1 on item 9 of the BDI-II)
* access to a computer with an Internet connection.

8. Measures:
Almost Perfect Scale- Revised (APS-R; Slaney et al., 2001): Discrepancy (α=.70), High Standards (α=.76), & Order (α=.94)
Frost Multidimensional Perfectionism Scale (FMPS, Frost et al., 1990): Concern Over Mistakes (α=.90), Doubts About Actions (α=.78), Parental Criticism (α=.89), Parental Expectations (α=.92), Personal Standards (α=.47) and Organization (α=.80).
Beck Depression Inventory (BDI-II; (Beck et al., 1996)) (α=.75)
Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988) (α=.84)
Automatic Thoughts Questionnaire (ATQ; Netemeyer et al., 2002) (α=.92)
Yale-Brown Obsessive Compulsive Scale (Y-BOCS; Goodman et al., 1989) (α=.84)
Perceived Stress Scale (PSS; Cohen, Kamarck, & Mermelstein, 1983) (α=.86)
The Unconditional Self-Acceptance Questionnaire(USAQ; Chamberlain & Haaga, 2001) (α=.87)
Main
outcomes
Secondary
outcomes
Highlighted dimensions are considered maladaptive forms of perfectionism

9. Design Open trial Perfectionism program
Screening (T0)
Perfectionism program
(45 days)
Post-intervention assessment (T1)

10. Results – main outcomes (standard analysis, n=17)
Perfectionism
Pre-test
Mean (SD)
Post-test
t Test
Cohen`s d
APS-R High Standards
42.71 (4.66)
36.94 (5.48)
4.17**
1.01
APS-R Order
23.00 (4.10)
21.06 (5.33)
2.12*
0.52
APS-R Discrepancy
49.94 (13.77)
42.29 (15.30)
2.17*
0.53
FMPS-Concern over Mistakes
28.41 (8.27)
22.82 (10.16)
2.63*
0.64
FMPS-Doubts about Actions
12.35 (3.74)
11.29 (3.86)
.96
0.23
FMPS-Parental criticism
13.06 (4.78)
11.71 (5.25)
1.36
0.33
FMPS-Parental expectations
18.12 (6.03)
17.76 (5.41)
.30
0.07
FMPS-Personal Sandards
28.12 (2.20)
25.18 (4.39)
3.12**
0.76
FMPS-Organization
27.35 (3.27)
25.59 (3.67)
2.46*
0.60
FMPS-Total score
(16.58)
88.76 (20.15)
2.06*
0.50

11. Results – main outcomes (intent-to-treat analysis, n=41)
Perfectionism
Pre-test
Mean (SD)
Post-test
t Test
Cohen`s d
APS-R High Standards
42.83 (3.94)
39.98 (5.82)
3.57**
0.56
APS-R Order
22.41 (4.38)
21.61 (4.90)
1.99*
0.31
APS-R Discrepancy
53.46 (15.94)
49.39 (18.23)
2.35*
0.36
FMPS-Concern over Mistakes
28.93 (8.83)
26.61 (10.11)
2.39*
0.37
FMPS-Doubts about Actions
12.78 (3.90)
12.34 (4.04)
0.96
0.15
FMPS-Parental criticism
11.41 (4.98)
10.85 (5.02)
1.34
0.21
FMPS-Parental expectations
17.12 (6.09)
16.98 (5.83)
0.05
FMPS-Personal Sandards
28.66 (3.11)
27.44 (4.35)
2.73**
0.43
FMPS-Organization
27.37 (3.18)
26.63 (3.47)
2.27*
0.35
FMPS-Total score
98.90 (19.76)
94.22 (21.53)
1.96*

12. Results – secondary outcomes (standard analysis, n=17)
Pre-test
Mean (SD)
Post-test
t Test
Cohen`s d
Depression
10.76 (6.46)
5.00 (4.75)
3.86**
0.94
Anxiety
8.53 (5.78)
6.06 (4.22)
2.41*
0.59
Obsessive-Compulsive Symptoms
6.00 (5.83)
3.59 (2.67)
1.79*
0.44
Automatic Thoughts
34.50 (13.08)
27.19 (10.79)
2.08*
0.52
Perceived Stress
19.37 (6.33)
13.81 (5.06)
3.65**
0.92
Unconditional Self-Acceptance
83.13 (20.82)
90.00 (19.75)
-2.91**
-0.73

13. Results – secondary outcomes (intent-to-treat, n=41)
Pre-test
Mean (SD)
Post-test
t Test
Cohen`s d
Depression
11.00 (5.84)
8.61 (5.99)
3.16**
0.49
Anxiety
9.76 (6.59)
8.66 (6.40)
2.24*
0.36
Obsessive-Compulsive Symptoms
7.05 (5.83)
6.05 (5.18)
1.73*
0.27
Automatic Thoughts
33.51 (11.26)
30.35 (10.53)
1.97*
0.32
Perceived Stress
19.57 (5.63)
17.23 (5.87)
3.02**
Unconditional Self-Acceptance
79.97 (19.97)
82.87 (20.29)
-2.57**
-0.42

14. Results – Recovery rate
% of participants with recovery rate >50%
Intent-to-treat (N=41)
Standard analysis (N=17)
BDI
26.8%
64.7%
BAI
14.6%
35.3%
APSR High Standards 0%
APSR Order
2.4%
5.9%
APSR Discrepancy
4.9%
FMPS Concern over mistakes
11.8%
FMPS Doubts about actions
FMPS Personal standards
FMPS Organization
FMPS Parental criticism
FMPS Parental expectations

15. Transdiagnostic process
Discussion
- Perfectionism significantly decreases following the intervention program
- Other psychological symptoms also improve following the perfectionism intervention
anxiety / depression / perceived stress / automatic thoughts / obsessive-compulsive symptoms
Anxiety & Depression improve more than Perfectionism (higher recovery rates)
Perfectionism – more stable (trait) as compared to depression & anxiety
What “amount” of change in perfectionism is necessary to produce changes in other psychological symptoms?
What are the mechanisms involved in changing psychological symptoms by addressing perfectionism?
What are the long term effect of perfectionism interventions?
Perfectionism
Transdiagnostic process
Anxiety & Depression improve more than Perfectionism (higher recovery rates)
More evidence to support the fact that perfectionism is a transdiagnostic process
Also, it raises important questions

16. Our study is not perfect :) (Limitations & future research)
Lack of a control group
Long-term effects of the intervention program
High attrition rate – can we improve programs to attract participants – improve program retention?
Intermediary measurements would help understand when the change starts and how it is maintained

17. Questions