پیش بینی افسردگی، اضطراب و صدمه به خود در نوجوانان: نقش کمال گرایی و استرس زندگی حاد

Despite the growing evidence that perfectionism is associated with adolescent psychological distress, few studies have investigated this relationship prospectively with measures designed for use in adolescent populations. In the present study, within a diathesis–stress framework, we investigated the extent to which perfectionism and acute life stress predict depression, anxiety and self-harm among adolescent school children (n = 515) over a 6 month period (Time 1–Time 2). Socially prescribed perfectionism (SPP), self-oriented perfectionism–critical (SOP-critical) and the associated interactions with acute life stress differentially predicted anxiety, depression and self-harm. Acute life stress was an independent predictor of depression, anxiety and self-harm. SPP predicted depression and interacted with acute life stress to predict self-harm. SOP-critical and the SOP-critical by acute life stress interaction predicted anxiety. Self-oriented perfectionism-striving (SOP-striving) did not predict any of the Time 2 measures of distress. The dimensions of perfectionism are differentially associated with psychological distress. Tailored clinical interventions focused on adolescent perfectionism should offer promise in tackling psychological morbidity in adolescence.

Psychological morbidity is pervasive in adolescence (O'Connor, Rasmussen, Miles, & Hawton, 2009). Although rates of depression are low in young children, they are comparable to those found in adults by middle adolescence (Southall & Roberts, 2002). Anxiety is also a common feature of adolescence (Essau, Leung, Conradt, Cheng, & Wong, 2008). In addition, recent findings from across Europe suggest that adolescent self-harm is prevalent, especially among females (Hawton & Rodham, 2006) with depression and anxiety frequently implicated in its aetiology (Hawton, Rodham, Evans, & Weatherall, 2002). Consequently, considerable research effort has focused on identifying psychological predictors of distress among adolescents (Ingram & Price, 2001). Perfectionism, the focus of the present study, is one such predictor with a strong and independent relationship to distress across the lifespan (Flett & Hewitt, 2002; O'Connor and Sheehy, 2001 and Shafran and Mansell, 2001). Although there is a large literature in adults (Enns & Cox, 2002; Hewitt and Flett, 1991 and Shafran and Mansell, 2001), comparatively few studies have investigated the relationship between perfectionism and psychological health in children and adolescents (Essau et al., 2008, O'Connor, 2007 and Rice and Preusser, 2002). This may be because there are few perfectionism scales designed for use with child and adolescent populations (O'Connor, Dixon, et al., 2009 and Rice et al., 2007). The Child and Adolescent Perfectionism Scale (CAPS; Flett, Hewitt, Boucher, Davidson, & Munro, 1997) is one such scale developed specifically for use with younger populations.1 It is modelled on Hewitt and Flett's adult Multidimensional Perfectionism Scale (MPS; Hewitt & Flett, 1991) and is comprised of two subscales: (a) Self-oriented perfectionism (SOP), defined as a strong motivation to be perfect, all-or-nothing thinking and self-reported high achievement expectations, and (b) Socially prescribed perfectionism (SPP) which assesses the extent to which an individual believes that others hold unrealistically high expectations of their behaviour. 2 Taking an overview of the child and adolescent depression literature, almost without exception, SPP is positively related to depression in clinical and non-clinical populations (Castro et al., 2004, Essau et al., 2008, Hewitt et al., 2002, Huggins et al., 2008 and McCreary et al., 2004;). SPP is also associated cross-sectionally with suicidal ideation, hopelessness and self-harm (Boergers et al., 1998, Donaldson et al., 2000, Enns et al., 2003, Hewitt et al., 1997, O'Connor, Fraser, et al., 2009, O'Connor, Rasmussen, and Hawton, 2009 and O'Connor, Rasmussen, Miles, et al., 2009). The case has yet to be made prospectively (see Enns et al., 2003). To our knowledge, this is the first study to investigate the utility of the CAPS to predict adolescent self-harm. Few studies have investigated the relationship between SPP and child and adolescent anxiety. Some studies have found a relationship between SPP and anxiety (Essau et al., 2008 and Hewitt et al., 2002) but others have found that the relationship does not hold when other key variables (e.g., baseline mood) are partialled out (McCreary et al., 2004). The inconsistent findings may reflect the paucity of sufficiently powered studies or it may be that SPP is more closely associated with depression and suicidal risk than anxiety. In support of the latter postulation, SPP may be particularly associated with depression and suicidality in adolescence as it is a time when young people are especially sensitive to public failure, social acceptance and social integration (Berndt, 1979, Hewitt et al., 1997 and Mack, 1986). The findings relating SOP to child or adolescent distress are equivocal. For example, SOP was associated with depression and anxiety among 10–15 year olds in one study (Hewitt et al., 2002) but it failed to predict concurrent depressive diagnostic status in another (Huggins et al., 2008), or suicide ideation among adolescent psychiatric patients in a further study (Hewitt et al., 1997). Drawing again from the adult literature, two explanations for these inconsistencies are plausible. The first focuses on the ongoing conceptual debate within the perfectionism literature which posits that perfectionism is comprised of adaptive as well as maladaptive components (e.g., Bieling et al., 2003 and Campbell and Di Paula, 2002). Consonant with this viewpoint, there is a growing consensus that perfectionism is usefully conceptualised as comprising two higher order (latent) dimensions/factors: personal standards (PS) and evaluative concerns (EC) perfectionism (see Dunkley et al., 2006, Hewitt et al., 2003, O'Connor et al., 2007, Shafran et al., 2002 and Shafran et al., 2003). PS perfectionism is the setting of high standards and goals for oneself whereas EC perfectionism is characterised by “overly critical evaluations of one's own behaviour, an inability to derive satisfaction from successful performance and chronic concerns about others' criticism and expectations” (Dunkley et al., 2006, p.65). PS perfectionism comprises the adaptive components of perfectionism including striving for perfectionism whereas EC perfectionism, the maladaptive factor, includes self-criticism and SPP (Dunkley et al., 2003 and Dunkley et al., 2006). In essence, this higher order dichotomy suggests that SOP is comprised of two sub-components, a striving-type component which is adaptive and a self-critical, maladaptive dimension. Consequently, it is the mixed nature of SOP which may account for the equivocal findings in the literature. Indeed, two recent studies (McCreary et al., 2004 and O'Connor, Dixon, et al., 2009) yielded clear support for Dunkley and colleagues' higher order conceptualisation. Specifically, they found that the SOP dimension was better modelled as two factors (SOP-striving and SOP-critical) with SPP scaling well as a single factor. As a result, we have employed the 3-factor version of the CAPS in the present study and predicted that SOP-critical and SPP but not SOP-striving would be associated with psychological distress. A second explanation for the unpredictable SOP findings concerns the role of stress and other moderators. In addition to being conceptually mixed, the SOP–distress relationship is known to vary as a function of the presence or absence of moderators, for example, stress (e.g., Hewitt et al., 2002) or coping (O'Connor & O'Connor, 2003). This explanation would be consistent with the diathesis–stress hypothesis; exponents of which point to the merits of investigating the extent to which the vulnerability associated with perfectionism is activated by stress (Flett et al., 1995, Hewitt and Flett, 1993, O'Connor and O'Connor, 2003 and Rice and Lapsley, 2001). In other words, it may be that the deleterious effect of SOP on well-being becomes especially apparent when activated by stress. By contrast, the relationship between SPP and depressive symptoms is more direct, less affected by moderating factors (Flett et al., 1995). With respect to stress, there is good evidence that the occurrence of negative life events contributes to the onset and maintenance of depression, anxiety and self-harm in childhood and adolescence (e.g., Hawton et al., 2002 and Ingram and Price, 2001). Although depression, anxiety and self-harm may have different aetiologies, for the most part, there is no consistent evidence in the perfectionism literature to posit differential hypotheses, so for the majority of the hypotheses we aggregated the different measures of distress. Therefore, in the present study, we investigated whether perfectionism differentially predicts psychological distress and the extent to which its effects are moderated by acute stress (i.e., life stress). We were particularly interested in acute stress in light of the recent findings suggesting that acute stress is potentially more important than chronic stress in depression (Muscatell, Slavich, Monroe, & Gotbib, 2009). The present study We recruited adolescents from secondary schools and measured their psychological distress (depression, anxiety and self-harm) and life stress at baseline and again six months later at Time 2. Six months was chosen as a suitable follow-up period as it fitted comfortably within a school academic year and it was also of sufficient duration to examine changes in acute life stress and psychological distress. We aimed to determine the extent to which acute life stress and perfectionism predicted psychological distress over time and whether there was evidence for the perfectionism diathesis–stress hypothesis. As the previous perfectionism research evidence is equivocal, we are limited in the directional hypotheses we can formulate. Nonetheless, we proposed four key hypotheses: (1) Acute life stress experienced during the course of the study would be an independent predictor of psychological distress (depression, anxiety and self-harm); (2) SPP and SOP-critical would be more strongly related to psychological distress than SOP-striving; (3) Consistent with Flett et al. (1995), the influence of SPP on depression would be direct and not moderated by acute stress; (4) The interaction between SOP-critical perfectionism and acute life stress experienced between Time 1 and Time 2 would explain additional variance in psychological distress beyond their independent effects.