Perfectionism as a transdiagnostic process: a clinical review

Perfectionism is a risk and maintaining factor for eating disorders, anxiety disorders and depression. The objective of this paper is to review the four bodies of evidence supporting the notion that perfectionism is a transdiagnostic process. First, a review of the literature was conducted that demonstrates the elevation of perfectionism across numerous anxiety disorders, depression, and eating disorders compared to healthy controls. Data is presented that shows perfectionism increases vulnerability for eating disorders, and that it maintains obsessive–compulsive disorder, social anxiety and depression as it predicts treatment outcome in these disorders. Second, evidence is examined showing that elevated perfectionism is associated with co-occurrence of psychopathology. Third, the different conceptualisations of perfectionism are reviewed, including a cognitive-behavioural conceptualisation of clinical perfectionism that can be utilised to understand this transdiagnostic process. Fourth, evidence that treatment of perfectionism results in reductions in anxiety, depression and eating pathology is reviewed. Finally,the importance of clinicians considering the routine assessment and treatment of perfectionism is outlined.

A case of anxiety disorder not otherwise specified (ADNOS): a transdiagnostic approach

The transdiagnostic approach to eating disorders has led to significant benefit for the research and treatment of "eating disorder not otherwise specified" (EDNOS). There is currently almost no research on "anxiety disorder not otherwise specified (ADNOS)." This case report describes a transdiagnostic approach to the treatment of ADNOS, using a modular framework. The treatment was successful in the short term but not in the longer term. It is concluded that increasing the evidence base for transdiagnostic treatment of anxiety disorders is a clinical and research priority.

What does a transdiagnostic approach have to offer the treatment of anxiety disorders?

Purpose: The purpose of this paper is to review the rationale for 'transdiagnostic' approaches to the understanding and treatment of anxiety disorders. Methods: Databases searches and examination of the reference lists of relevant studies were used to identify papers of relevance. Results: There is increasing recognition that diagnosis-specific interventions for single anxiety-disorders are of less value than might appear since a large proportion of patients have more than one co-existing anxiety disorder and the treatment of one anxiety disorder does not necessarily lead to the resolution of others. As transdiagnostic approaches have the potential to address multiple co-existing anxiety disorders they are potentially more clinically relevant than single anxiety disorder interventions. They may also have advantages in ease of dissemination and in treating anxiety disorder not otherwise specified. Conclusions: The merits of the various transdiagnostic cognitive-behavioral approaches that have been proposed are reviewed. Such approaches have potential benefits, particularly in striking the balance between completely idiosyncratic formulations and diagnosis-driven treatments of anxiety disorders. However, caution is needed to ensure that transdiagnostic theories and treatments benefit from progress made by research on diagnosis-specific treatments, and further empirical work is needed to identify the shared maintaining processes that need to be targeted in the treatment of anxiety disorders.

Effects of a Transdiagnostic Internet Intervention («velibra») for Anxiety Disorders in Primary Care: Results of a Randomized Controlled Trial

Internet-based cognitive behavioral self-help treatment (ICBT) for anxiety disorders has shown promising results in several trials, but there is yet a lack of studies of ICBT in „real world” primary care settings. In this randomized controlled trial we recruited participants through general practitioners. The aim of the study was to examine whether treatment-as-usual (TAU) in primary care settings plus ICBT is superior to TAU alone in reducing anxiety symptoms and other outcome measures among individuals meeting diagnostic criteria of a least one of three anxiety disorders (social anxiety disorder, panic disorder with or without agoraphobia, generalized anxiety disorder). 150 adults fulfilling diagnostic criteria for a least one of the anxiety disorders according to a diagnostic interview are randomly assigned to one of the two conditions: TAU plus ICBT versus TAU. Randomization is stratified by primary disorder, medication (yes/no) and concurrent psychotherapy. ICBT consists of a transdiagnostic and tailored Internet-based self-help program for several anxiety disorders which also includes cognitive bias modification for interpretation (CBM-I). Primary outcomes are symptoms of disorder-specific anxiety measures and diagnostic status after the intervention (9 weeks). Secondary outcomes include primary outcomes at 3-month follow-up and secondary measures such as general symptomatology, depression, quality of life, adherence to ICBT and satisfaction with ICBT. The study is currently being completed. Primary results along with results for specific subgroups (e.g. primary diagnosis, concurrent medication and/or psychotherapy) will be presented and discussed.

A Transdiagnostic Social Skills Intervention; Using a Structured Story to Teach Children How to Ask a Friend to Play

An (independent samples comparison) controlled study was conducted to assess the efficacy of a novel approach to social skills training for children in a local socialization group at Knippenberg, Patterson & Associates (KPA). The treatment condition involved the combination of a Structured Story (i.e., novel bibliotherapy technique for children with social skills deficits), and a behavioral rehearsal (or role-play) segment, where the children practiced the target social skill featured in the Structure Story. The control group did not receive the Structured Story nor the behavioral rehearsal. Children in both groups engaged in ten-minutes of free play that was videorecorded for later observation and scoring by the principal investigator. Two target behaviors were assessed; asking a friend to play, and duration of joint play between two or more peers. The results did not show significant differences for either target variable between the group that received the novel intervention and the control group. Limitations of the current study and implications for further research are discussed.

A Transdiagnostic Approach to Understanding Eating Disorders

Categorical models dominate the eating disorder field, but the tandem use of categorical and dimensional models has been proposed. A transdiagnostic dimensional model, number of lifetime eating disorder behaviors (LEDB), was examined with respect to (1) its relationship to a variety of indicators of the individual's functioning, (2) the degree to which it was influenced by genetic and environmental risk factors, and (3) exposure to specific environmental risk factors. Data from self-report and interview from 1002 female twins (mean age = 34.91 years, SD = 2.09) were examined. While 15.4% women met criteria for a lifetime eating disorder, 29% had at least one LEDB. The dimensional measure provided an indicator of associated functioning, and was influenced primarily by the nonshared environment. The number of LEDB was associated with the degree of impaired functioning. This impairment was associated with conflict between parents and criticism from parents when growing up.

Cognitive behaviour therapy for low self-esteem: A preliminary randomized controlled trial in a primary care setting

Background and Objectives Low self-esteem (LSE) is associated with psychiatric disorder, and is distressing and debilitating in its own right. Hence, it is frequent target for treatment in cognitive behavioural interventions, yet it has rarely been the primary focus for intervention. This paper reports on a preliminary randomized controlled trial of cognitive behaviour therapy (CBT) for LSE using Fennell’s (1997) cognitive conceptualisation and transdiagnostic treatment approach ( [Fennell, 1997] and [Fennell, 1999]). Methods Twenty-two participants were randomly allocated to either immediate treatment (IT) (n = 11) or to a waitlist condition (WL) (n = 11). Treatment consisted of 10 sessions of individual CBT accompanied by workbooks. Participants allocated to the WL condition received the CBT intervention once the waitlist period was completed and all participants were followed up 11 weeks after completing CBT. Results The IT group showed significantly better functioning than the WL group on measures of LSE, overall functioning and depression and had fewer psychiatric diagnoses at the end of treatment. The WL group showed the same pattern of response to CBT as the group who had received CBT immediately. All treatment gains were maintained at follow-up assessment. Limitations The sample size is small and consists mainly of women with a high level of educational attainment and the follow-up period was relatively short. Conclusions These preliminary findings suggest that a focused, brief CBT intervention can be effective in treating LSE and associated symptoms and diagnoses in a clinically representative group of individuals with a range of different and co-morbid disorders.

Biased interpretation in perfectionism and its modification

Perfectionism is a transdiagnostic construct associated with a range of diagnoses, including depression, eating disorders and obsessive compulsive disorder. Treatments that directly target perfectionist cognitions have been shown to successfully reduce associated pathologies. However, the way in which they do this is not clear. We set out to assess the role of one candidate mechanism of action, namely the cognitive process of interpretation of ambiguity. In one experiment we looked for associations between biased interpretation and perfectionism. In a second, we manipulated interpretations, thereby providing a strong test of their aetiological significance. Results from the first experiment confirmed the presence of biased interpretation in perfectionism and demonstrated that these are highly specific to perfection relevant information, rather than reflecting general negativity. The second experiment succeeded in manipulating these perfection relevant interpretations and demonstrated that one consequence of doing so is a change in perfectionist behaviour. Together, these data experimentally demonstrate that biased interpretation of perfection relevant ambiguity contributes to the maintenance of perfectionism, but that it is also possible to reverse this. Clinical implications include the identification of one likely mechanism of therapeutic change within existing treatments, as well as identification of an appropriate evidence based focus for future treatment development. Targeting underlying functional mechanisms, such as biased interpretation, has the potential to offer transdiagnostic benefits.

Internet-Based Guided Self-Help for Several Anxiety Disorders: A Randomized Controlled Trial Comparing a Tailored With a Standardized Disorder-Specific Approach

Internet-delivered self-help with minimal therapist guidance has shown promising results for a number of diagnoses. Most of the evidence comes from studies evaluating standardized disorder-specific treatments. A recent development in the field includes transdiagnostic and tailored Internet-based treatments that address comorbid symptoms and a broader range of patients. This study evaluated an Internet-based tailored guided self-help treatment, which targeted symptoms of social anxiety disorder, panic disorder with or without agoraphobia, and generalized anxiety disorder. The tailored treatment was compared both with standardized disorder-specific Internet-based treatment and with a wait-list control group. Both active treatment conditions were based on cognitive-behavioral therapy and lasted for 8 weeks. A total of 132 individuals meeting diagnostic criteria for at least one of the anxiety disorders were randomly assigned to 1 of the 3 conditions. Both treatment groups showed significant symptom reductions as compared with the wait-list control group on primary disorder-unspecific measures of anxiety, depression, and general symptomatology and on secondary anxiety disorder-specific measures. Based on the intention-to-treat sample, mean between-group effect sizes were d = 0.80 for the tailored treatment and d = 0.82 for the standardized treatment, versus wait-list controls. Treatment gains were maintained at 6-month follow-up. No differences were found between the 2 active treatment conditions on any of the measures, including a telephone-administered diagnostic interview conducted at posttreatment. The findings suggest that both Internet-based tailored guided self-help treatments and Internet-based standardized treatments are promising treatment options for several anxiety disorders

Advancing psychotherapy and evidence-based psychological interventions

Psychological models of mental disorders guide research into psychological and environmental factors that elicit and maintain mental disorders as well as interventions to reduce them. This paper addresses four areas. (1) Psychological models of mental disorders have become increasingly transdiagnostic, focusing on core cognitive endophenotypes of psychopathology from an integrative cognitive psychology perspective rather than offering explanations for unitary mental disorders. It is argued that psychological interventions for mental disorders will increasingly target specific cognitive dysfunctions rather than symptom-based mental disorders as a result. (2) Psychotherapy research still lacks a comprehensive conceptual framework that brings together the wide variety of findings, models and perspectives. Analysing the state-of-the-art in psychotherapy treatment research, “component analyses” aiming at an optimal identification of core ingredients and the mechanisms of change is highlighted as the core need towards improved efficacy and effectiveness of psychotherapy, and improved translation to routine care. (3) In order to provide more effective psychological interventions to children and adolescents, there is a need to develop new and/or improved psychotherapeutic interventions on the basis of developmental psychopathology research taking into account knowledge of mediators and moderators. Developmental neuroscience research might be instrumental to uncover associated aberrant brain processes in children and adolescents with mental health problems and to better examine mechanisms of their correction by means of psychotherapy and psychological interventions. (4) Psychotherapy research needs to broaden in terms of adoption of large-scale public health strategies and treatments that can be applied to more patients in a simpler and cost-effective way. Increased research on efficacy and moderators of Internet-based treatments and e-mental health tools (e.g. to support “real time” clinical decision-making to prevent treatment failure or relapse) might be one promising way forward.

The structure of psychopathological symptoms and the associations with DSM-diagnoses in treatment seeking individuals

BACKGROUND: Research on comorbidity of psychiatric disorders identifies broad superordinate dimensions as underlying structure of psychopathology. While a syndrome-level approach informs diagnostic systems, a symptom-level approach is more likely to represent the dimensional components within existing diagnostic categories. It may capture general emotional, cognitive or physiological processes as underlying liabilities of different disorders and thus further develop dimensional-spectrum models of psychopathology. METHODS: Exploratory and confirmatory factor analyses were used to examine the structure of psychopathological symptoms assessed with the Brief Symptom Inventory in two outpatient samples (n=3171), including several correlated-factors and bifactor models. The preferred models were correlated with DSM-diagnoses. RESULTS: A model containing eight correlated factors for depressed mood, phobic fear, aggression, suicidal ideation, nervous tension, somatic symptoms, information processing deficits, and interpersonal insecurity, as well a bifactor model fit the data best. Distinct patterns of correlations with DSM-diagnoses identified a) distress-related disorders, i.e., mood disorders, PTSD, and personality disorders, which were associated with all correlated factors as well as the underlying general distress factor; b) anxiety disorders with more specific patterns of correlations; and c) disorders defined by behavioural or somatic dysfunctions, which were characterised by non-significant or negative correlations with most factors. CONCLUSIONS: This study identified emotional, somatic, cognitive, and interpersonal components of psychopathology as transdiagnostic psychopathological liabilities. These components can contribute to a more accurate description and taxonomy of psychopathology, may serve as phenotypic constructs for further aetiological research, and can inform the development of tailored general and specific interventions to treat mental disorders.

More adaptive versus less maladaptive coping: What is more predictive of symptom severity? Development of a new scale to investigate coping profiles across different psychopathological syndromes

BACKGROUND: Lack of adaptive and enhanced maladaptive coping with stress and negative emotions are implicated in many psychopathological disorders. We describe the development of a new scale to investigate the relative contribution of different coping styles to psychopathology in a large population sample. We hypothesized that the magnitude of the supposed positive correlation between maladaptive coping and psychopathology would be stronger than the supposed negative correlation between adaptive coping and psychopathology. We also examined whether distinct coping style patterns emerge for different psychopathological syndromes. METHODS: A total of 2200 individuals from the general population participated in an online survey. The Patient Health Questionnaire-9 (PHQ-9), the Obsessive-Compulsive Inventory revised (OCI-R) and the Paranoia Checklist were administered along with a novel instrument called Maladaptive and Adaptive Coping Styles (MAX) questionnaire. Participants were reassessed six months later. RESULTS: MAX consists of three dimensions representing adaptive coping, maladaptive coping and avoidance. Across all psychopathological syndromes, similar response patterns emerged. Maladaptive coping was more strongly related to psychopathology than adaptive coping both cross-sectionally and longitudinally. The overall number of coping styles adopted by an individual predicted greater psychopathology. Mediation analysis suggests that a mild positive relationship between adaptive and certain maladaptive styles (emotional suppression) partially accounts for the attenuated relationship between adaptive coping and depressive symptoms. LIMITATIONS: Results should be replicated in a clinical population. CONCLUSIONS: Results suggest that maladaptive and adaptive coping styles are not reciprocal. Reducing maladaptive coping seems to be more important for outcome than enhancing adaptive coping. The study supports transdiagnostic approaches advocating that maladaptive coping is a common factor across different psychopathologies.