Does perfectionism in bipolar disorder pedigrees mediate associations between anxiety/stress and mood symptoms?
Corry et al. Int J Bipolar Disord
Does perfectionism in bipolar disorder pedigrees mediate associations between anxiety/stress and mood symptoms?
Justine Corry 0 2
Melissa Green 0 2 4
Gloria Roberts 0 2
Janice M. Fullerton 3 4
Peter R. Schofield 3 4
Philip B. Mitchell 0 1 2
0 School of Psychiatry, University of New South Wales , Randwick, NSW 2031 , Australia
1 Prince of Wales Hospital , Randwick, NSW 2031 , Australia
2 Black Dog Institute, Prince of Wales Hospital , Randwick, NSW 2031 , Australia
3 School of Medical Sciences, University of New South Wales , Randwick, NSW , Australia
4 Neuroscience Research Australia , Randwick, NSW , Australia
Background: Bipolar disorder (BD) and the anxiety disorders are highly comorbid. The present study sought to examine perfectionism and goal attainment values as potential mechanisms of known associations between anxiety, stress and BD symptomatology. Measures of perfectionism and goal attainment values were administered to 269 members of BD pedigrees, alongside measures of anxiety and stress, and BD mood symptoms. Regression analyses were used to determine whether perfectionism and goal attainment values were related to depressive and (hypo) manic symptoms; planned mediation models were then used to test the potential for perfectionism to mediate associations between anxiety/stress and BD symptoms. Results: Self-oriented perfectionism was associated with chronic depressive symptoms; socially-prescribed perfectionism was associated with chronic (hypo)manic symptoms. Self-oriented perfectionism mediated relationships between anxiety/stress and chronic depressive symptoms even after controlling for chronic hypomanic symptoms. Similarly, socially-prescribed perfectionism mediated associations between anxiety/stress and chronic hypomanic symptoms after controlling for chronic depressive symptoms. Goal attainment beliefs were not uniquely associated with chronic depressive or (hypo)manic symptoms. Conclusions: Cognitive styles of perfectionism may explain the co-occurrence of anxiety and stress symptoms and BD symptoms. Psychological interventions for anxiety and stress symptoms in BD might therefore address perfectionism in attempt to reduce depression and (hypo)manic symptoms in addition to appropriate pharmacotherapy.
Bipolar disorder; Anxiety; Stress; Psychology
The high rate of comorbidity between anxiety disorders
and bipolar disorder is well established
(Pavlova et al.
. Anxiety disorders have been shown to precede
the onset of bipolar disorder (BD)
(de Graaf et al. 2003;
Perugi et al. 2001)
and there are high rates of anxiety
disorders in families affected by BD
(Nurnberger et al.
2011; Perich et al. 2015; Merikangas et al. 2014)
However, the mechanisms that underlie the comorbidity
between anxiety disorders and BD are not fully
(Mitchell 2015; Provencher et al. 2012)
. To move
beyond purely descriptive studies, we propose that these
disorders co-occur because they share common
(Harvey et al. 2004)
. Cognitive styles
are important maintaining factors in cognitive models
(Harvey et al. 2004)
, and we
propose that the cognitive style of perfectionism may be an
explanatory factor in the high co-occurrence of BD and
AD’s. Here, we specifically examined perfectionism as a
potential mediator of known associations between
anxiety and stress symptoms and mood symptomatology
(Alloy et al. 2006; Boylan et al. 2004; Corry et al. 2013)
a large family study.
The development of BD is influenced strongly by
genetics, accounting for as much as 85% of the variance in who
(McGuffin et al. 2003)
. In families, a
summary of 5 studies estimated that the risk of an affective
disorder in first degree relatives of those with BD ranges
from 24 to 31% and the risk of BD ranges from 7 to 22%
(Merikangas et al. 2002)
. Given this high genetic
contribution to the development of BD, there remains the task
of identifying how and when this biological vulnerability
is expressed with more proximal biological,
psychological and environmental triggers being important factors
(Johnson 2005; Jones and Bentall 2008)
have higher rates of Schizoaffective Disorder (BD type),
BD-I, BD-II and Major Depressive Disorder that control
families (Gershon et al. 1982). There is also emerging
evidence that the family environment plays an
important role in influencing the development of beliefs and
attitudes related to achievement and attainment of goals
(Johnson 2005; Chen and Johnson 2012)
. Hence, studies
of extended families with some members diagnosed with
BD may be useful to determine the contribution of
perfectionistic cognitions and beliefs relating to goal
attainment to anxiety, stress, and other core mood symptoms
such as depression and hypomania.
Cognitive models of the development of
psychopathology propose that cognitive, mood and behavioural
symptoms arise when maladaptive beliefs and
cognitions are triggered by congruent life events
(Beck et al.
. Recently, cognitive models of BD symptoms and
mood dysregulation have been proposed that attempt to
explain both the depressive and (hypo)manic symptoms
characteristic of BD
(Holmes et al. 2008; Mansell et al.
. Mansell et al. (2007) have proposed a
transdiagnostic model of mood dysregulation and bipolar disorder,
within which it is proposed that self-critical or shaming
beliefs may be important in driving anxious thoughts and
cognitive appraisals of affect, as well as bodily sensations
that ultimately influence the ascent into (hypo)mania or
descent into depression
(Mansell et al. 2007)
parallel, a separate cognitive model of BD emphasizes the role
that anxiety plays in the development of BD symptoms
(Holmes et al. 2008). The model of Mansell et al. (2007)
in particular draws on findings that perfectionism is a
core cognitive style of BD, along with high self-criticism
and an emphasis on goal attainment and avoidance of
(Alloy et al. 2009a; Lam et al. 2004; Mansell and
Pedley 2008; Scott et al. 2000)
. For example, in a
prospective study, self-criticism, performance focus and high
self-standards interacted with congruent life events to
predict both depressive and (hypo)manic symptoms in
those with BD-II and cyclothymia (Francis-Raniere et al.
2006). Lam et al. (2004) found that beliefs related to goal
attainment distinguished those with BD from normal
controls and were correlated with number of
hospitalizations for mania and BD episodes in general
(Lam et al.
. Hewitt et al. (1998) examined perfectionism as a
multidimensional construct in a mixed sample of
unipolar and BD patients. Hewitt found that self-oriented
perfectionism (whereby the individual has high standards
for themselves) was uniquely associated with chronic
depression symptoms, while socially-prescribed
perfectionism (whereby individuals perceive that others have
high standards for them) was been uniquely associated
with chronic (hypo)manic symptoms (Hewitt et al. 1998).
A perfectionistic cognitive style has also been associated
with anxiety and stress symptoms
(Hewitt and Flett 2002;
Frost and DiBartolo 2002; Wheeler et al. 2011)
Previous associations with perfectionism extend to variations
in state and trait anxiety
(Flett et al. 1995)
, social anxiety
(Juster et al. 1996)
(Antony et al. 1998)
, panic disorder
(Antony et al.
and a tendency to worry
with this, greater levels of perfectionism have also been
associated with greater cortisol responses to stress
in situations designed to induce a fear of negative evaluation
(Wirtz et al. 2007)
a core cognitive style in social anxiety
disorder. These findings, which confirm perfectionism as
a key cognitive style in both BD and the anxiety
disorders, provided the impetus to examine perfectionism as a
potential mediator of known associations between
anxiety and stress symptoms and mood symptomatology.
Consistent with the psychological models of BD
(Holmes et al. 2008; Mansell et al. 2007)
, we have
previously reported that anxiety and stress symptoms
mediated the effects of self-critical perfectionism and
goal attainment beliefs on current bipolar depressive
symptoms after controlling for current hypomanic
(Corry et al. 2013)
. For hypomanic symptoms, stress
symptoms were a significant mediator of the relationship
between self-critical perfectionism and current
hypomanic symptoms; however, these mediation models were
no longer significant after controlling current depressive
symptoms. Similar findings were reported by
O’GarroMoore et al. (2015) using prospective data from those
with bipolar spectrum disorders. Of the six cognitive
styles examined as mediators, only perfectionism was a
significant mediator of the relationship between the
presence of an anxiety disorder and depressive symptoms. No
cognitive styles significantly mediated the relationship
between anxiety disorder and hypomanic symptoms.
This study thus examined the hypotheses that
perfectionism and goal attainment values would mediate
the associations between (subclinical) anxiety/stress
symptoms and hypomanic and depressive
symptomatology, in BD patients and their unaffected relatives. We
chose to extend the work of Hewitt et al. by examining
perfectionism as a multidimensional construct in a
family sample. We hypothesized that: (1) self-oriented
perfectionism would mediate the relationship between anxiety
and stress symptoms and chronic depressive symptoms;
and (2) socially-prescribed perfectionism and goal
attainment values would mediate the relationship between
stress and anxiety symptoms and chronic (hypo)manic
symptoms. In line with Hewitt et al. (1998) findings, these
predictions reflected our expectation that: (1)
self-oriented perfectionism would be uniquely related to chronic
depression depressive symptoms; and (2)
socially-prescribed perfectionism and goal attainment values would
be uniquely related to chronic (hypo)manic symptoms.
The participants in the current study had previously
been recruited through a BD molecular genetics
pedigree research study
(McAuley et al. 2009; Fullerton et al.
. All families were ascertained after initial
consultation with a proband with BD (using the Family Interview
for Genetic Studies; FIGS). Each pedigree member
provided informed consent prior to inclusion in the study.
All individuals were assessed using the Diagnostic
Interview for Genetic Studies (DIGS) (Nurnberger et al. 1994),
with interviews being undertaken by experienced
medical practitioners, psychologists and psychiatric nurses
trained in this instrument. Information obtained from
the FIGS, DIGS and medical records was used to generate
best-estimate Research Diagnostic Criteria (RDC)
diagnoses for Bipolar I disorder (BD-I), Bipolar II Disorder
(BD-II), Schizoaffective Disorder Manic Type (SZMA)
or Recurrent Unipolar Major Depression (RUD). As we
were interested in examining both sub-syndromal and
syndromal mood disorder symptoms, we also included
those participants who did not meet formal RDC criteria
for a mood disorder but who may still be at greater risk
of developing symptomatology due to increased familial
The questionnaire for the current study was posted
to all contactable first and second degree relatives of
the proband in the 67 pedigrees (n = 735) with a return
deadline of 24 days. After 37 days, 267 responses were
received. At 45 days, a secondary mail-out was
conducted to those individuals who had failed to respond,
which yielded an additional 76 responses giving a 46.6%
response rate. Of the 343 individuals who completed the
questionnaires, 325 individuals responded to over 95% of
the 164 items, and 297 individuals responded to over 99%
of items. Of the 67 families included in the mail-out, 47
had 2 or more members complete over 95% of the
survey. Missing data was imputed using the mean response
of other items within the same questionnaire or sub-scale
(Tabachnick and Fidell 2013)
completing less than 95% of the survey were not included
in the analysis in order to reduce the impact of
non-randomly missing datapoints in the dataset
Internal State Scale (ISS)
The Internal State Scale is a 15-item self-report measure
designed to provide a simple mood state ascertainment
for those with BD
(Bauer et al. 1991)
. There are four
sub-scales—Activation, Well Being, Depression Index
and Perceived Conflict—which are rated using a visual
analogue line scale. An algorithm using scores from the
Activation and Wellbeing sub-scales identifies
individuals in euthymic, depressed, manic and mixed states. The
ISS has been found to discriminate well, with moderate
kappas found between clinician-determined diagnostic
status and that determined by the ISS
(Bauer et al. 1991;
Bauer et al. 2000; Glick et al. 2003)
General Behaviour Inventory (GBI)
The GBI is a measure of chronic-intermittent forms of
affective disorders and identifies the full range of severity
of unipolar and BD—from sub-syndromal to syndromal
(Depue et al. 1981, 1989)
. It consists of three clusters of
items: depressive, hypomanic and biphasic (defined as
the tendency to vacillate between depression and
hypomania in the same item). The GBI has 73 items that are
scored on a 0–4 Likert scale related to the chronicity of
the symptom described. It is possible to use the
scoring system of the GBI as a Likert scale yielding
continuous scores of affective disturbance or dysregulation in
the domains of depressive, hypomanic and biphasic
symptoms. We used a selection of ten items from the
depression domain of which the majority selected being
consistent with a recent factor analysis informing the
development of a shorter version of the GBI (Youngstrom
et al. 2013). The items were: (1) Have you had periods
of sadness and depression when almost everything gets
on your nerves and makes you irritable or angry (other
than related to the menstrual cycle)?; (2) Have there been
times of several days or more when you were so sad that
it was quite painful or you felt that you couldn’t stand it?;
(3) Have there been times when you looked back over
your life and could see only failures or hardships?; (4)
Have there been times when you were feeling low and
depressed, and you also had to struggle very hard to
control inner feelings of rage or an urge to smash or destroy
things?; (5) Have there been times when you exploded at
others and afterwards felt bad about yourself?; (6) Have
there been times when you hated yourself or felt that you
were stupid, ugly, unlovable, or useless? (7) Have there
been times of several days or more when you really got
down on yourself and felt worthless?; (8) Have you had
periods when it seemed that the future was hopeless and
things could not improve?; (9) Have there been periods
lasting several days or more when you were so down in
the dumps that you thought you might never snap out
of it?; and (10) Have there been times when you have felt
that you would be better off dead? All 27 items for the
hypomanic and biphasic domains were administered. The
GBI has been extensively validated and possesses good
(Depue et al. 1981, 1989)
Depression, Anxiety and Stress Scale (DASS)
The DASS is a 42-item scale measuring the negative
emotional states of depression, anxiety and stress with
each sub-scale having 14 items
(Lovibond and Lovibond
. In the current study, we focused on the Anxiety
and Stress sub-scales. The anxiety sub-scale is a measure
of the acute autonomic fear response. The stress
subscale measures the state of persistent arousal and tension
with a low threshold for becoming upset or frustrated.
For clinical utility, DASS scores can be categorized into
normal, mild, moderate, severe and extreme severe
categories for each emotional state
(Lovibond and Lovibond
. The DASS has been shown to have good
(Lovibond and Lovibond 1995a;
Lovibond and Lovibond 1995b)
Multidimensional Perfectionism Scale (MPS)
The MPS is a 45-item scale assessing three dimensions
of perfectionism: (1) self-oriented perfectionism (i.e. the
tendency to establish perfectionistic standards for
oneself ); (2) socially-prescribed perfectionism (i.e. The
tendency to believe that others have unrealistic standards
for oneself ); and (3) other-oriented perfectionism (i.e.
the tendency to have perfectionistic expectations of
(Hewitt and Flett 1991)
. The MPS has been shown
to have good reliability, internal consistency and validity
(Hewitt and Flett 1991; Hewitt et al. 1991)
. The present
study focused on self-oriented perfectionism (SO) and
socially-prescribed perfectionism (SP) and therefore only
these sub-scales of the MPS were administered.
Dysfunctional Attitudes Scale (DAS)
The original DAS consists of two 40-item parallel
questionnaires items that tap various cognitive schemas
proposed to place individuals at risk of depression
(Weissman and Beck 1978)
. Factor analytic
investigation of this scale has yielded various factors that relate
to these cognitive schemas. We used the goal
attainment factor from Lam et al. (2004) which is proposed to
measure the intensity of beliefs related to positive affect,
extraversion and achievement-striving
(Lam et al. 2004)
The goal attainment factor was found to be highly reliable
(6 items; α = 0.79).
Analyses were conducted using SPSS Statistics package
and MPlus using procedures to account for the nested
nature of the dataset. Pearson correlations were
calculated for bivariate associations between the measures
of cognitive style (perfectionism and goal attainment),
chronic BD symptomatology (i.e., depression and
hypomania), anxiety and stress symptoms, demographics and
current episode. In order to test whether perfectionism
and goal attainment values were uniquely related to BD
symptomatology, we used generalized estimating
equations (GEE procedure) to generate two regression
models: one for chronic depressive symptoms and one for
chronic (hypo)manic symptoms. We controlled for the
effects of gender, age, presence vs absence of current BD
episode and chronic depressive or (hypo)manic
symptoms (depending on the independent variable). All
variables were entered in one block so that the beta for any
one independent variable represents the degree of
association between that dependent variable and the
independent variable after controlling for all other dependant
variables in the model
(Tabachnick and Fidell 2013)
Mediation analyses were conducted using
nonparametric bootstrapping methods to test the significance of the
proposed mediators in our models using Mplus (
et al. 1998
). Two separate mediation models were used for
both chronic depressive symptoms and chronic (hypo)
manic symptoms with the analysis comprising of four
mediation models in total. In the first two models, the
tendency to experience chronic depressive symptoms was the
dependent variable, self-oriented and socially-prescribed
perfectionism were entered simultaneously as the
potential mediators, and anxiety and stress symptoms were the
independent variables. These analyses were repeated for
(hypo)manic symptoms as the dependent variable.
For demonstration of mediation, the independent
variable (anxiety and stress symptoms) must be related to the
dependent variable (chronic depressive and hypo/manic
symptoms), the independent variable must be related
to the proposed mediating variables (self-oriented
perfectionism and socially-prescribed perfectionism and
goal attainment values), and the relationship between
the mediating variables and the dependent variable (the
indirect effect) should be stronger than the
relationship between the independent variable and the
dependent variable (the direct effect). Using a nonparametric
bootstrapping approach to mediation, the indirect effect
is generated as a point estimate with 95% confidence
intervals. If zero is not included in the 95% confidence
intervals, it can be concluded that the indirect effects are
significantly different from zero at p < 0.05 (two-tailed)
and that partial or full mediation is present. We also
included age, gender, the presence of a depressive, (hypo)
manic or mixed episode as covariates in our analyses, and
the opposing mood state (chronic depressive symptoms
or chronic hypomanic/biphasic symptoms).
We also conducted additional analyses examining these
four models separately for the affected group and
unaffected group. These are reported in the Additional file 1.
The sample comprised 269 subjects from 56
pedigrees of whom 17.5% (n = 47) had BD-I; 6.3% (n = 17)
BD-II; 8.9% (n = 24) recurrent unipolar depression;
5.2% (n = 14) schizoaffective disorder (bipolar type);
and 62.1% (n = 167) unaffected relatives who did not
meet formal diagnostic criteria for any mood disorder.
Descriptive statistics for the total sample are detailed in
Table 1. T tests between affected and unaffected subjects
showed significant differences between the two groups
on the DASS stress sub-scale (p < 0.001). The same
pattern of results was observed for anxiety scores: those
with a mood disorder diagnosis had higher anxiety scores
(p < 0.001). The mean scores for the stress and anxiety
sub-scales of the DASS were low—in the normal range
according the DASS severity categories
. There were no significant differences
between those affected and unaffected on current rates
of depressive, (hypo)manic or mixed episodes (as
measured by the ISS). Those in the affected groups,
however, had higher levels of self-orientated perfectionism
(mean = 14.36, SD = 6.12 v. mean = 16.89, SD = 6.86;
t(267) = −3.15, p < 0.001). There were no significant
differences between the two groups on measures
sociallyprescribed perfectionism or goal attainment values.
Table 2 shows Pearson’s r correlations between the
measures included in the analysis. All variables were
correlated in the expected directions. Both measures of
perfectionism (self-oriented and socially-prescribed) and
goal attainment values were significantly correlated with
chronic depression and (hypo)manic symptoms. Anxiety
and stress symptoms were also significantly correlated
with chronic depression and (hypo)manic symptoms.
Generalized estimating equation regression models
The first model demonstrates that self-oriented
perfectionism was the only significant predictor of
chronic depressive symptoms (as measured by the
GBI), after controlling for other independent variables
(Table 3). No other cognitive style predicted depressive
ISS Internal State Scale, GBI Depression General Behaviour Inventory Depression sub-scale, GBI Hypomanic/Biphasic General Behaviour Inventory Biphasic/Hypomanic
sub-scale, DASS Anxiety Depression Anxiety Stress Scale-Anxiety sub-scale, DASS Stress Depression Anxiety Stress Scale-Stress scale, MPS Multidimensional
Perfectionism Scale, DAS Dysfunctional Attitudes Scale
*** p < 0.001
ISS Internal State Scale, GBI depression General Behaviour Inventory Depression sub-scale, GBI hypomanic/biphasic General Behaviour Inventory Biphasic/Hypomanic
sub-scale, DASS anxiety Depression Anxiety Stress Scale-Anxiety sub-scale, DASS stress Depression Anxiety Stress Scale-Stress scale, MPS self-oriented Multidimensional
Perfectionism scale Self-Oriented sub-scale, MPS socially-prescribed Multidimensional Perfectionism scale Socially-Prescribed sub-scale, DAS goal attainment
Dysfunctional Attitudes Goal Attainment Factor
* p < 0.05; ** p < 0.01 (these analyses are exploratory and therefore no adjustments for multiple comparisons have been made)
symptomatology, but other significant predictors were
a current depressive episode (as determined by the ISS)
and chronic (hypo)manic symptomatology (as measured
by the GBI). Being female was also associated with higher
levels of chronic depressive symptoms.
The second model showed that only socially-prescribed
perfectionism significantly predicted chronic (hypo)
manic symptomatology, after controlling for the other
independent variables (Table 3). Self-oriented
perfectionism was not a significant predictor. Other significant
predictors of chronic (hypo)manic symptomatology were
chronic depressive symptoms and a current hypomanic
episode (as determined by the ISS). Goal attainment
values only approached significance in this model (p < 0.10).
Being male was also associated with higher levels of
chronic (hypo)manic symptoms.
As goal attainment values was not a significant predictor
in the generalized estimating equation regression models
this cognitive style is not considered further in the
mediation models. In the two mediation models where chronic
depressive symptoms was the dependent variable, only
self-oriented perfectionism mediated the relationship
between both anxiety and stress symptoms and chronic
depressive symptoms (Table 4). Socially-prescribed
perfectionism was not a significant mediator. For anxiety
symptoms, the true indirect effects was estimated to lie
between 0.05 and 0.17. For stress symptoms, the true
indirect effects were estimate to lie between 0.04 and 0.17.
Table 3 Generalized Estimating Equations Using
Multidimensional Perfectionism Scale Dimensions and Goal
Attainment Values to Predict Chronic Depressive
and Chronic Hypomanic/Biphasic symptoms
Predicting chronic unipolar symptoms
DAS: goal attainment factor
MPS: self-oriented perfectionism
MPS: socially-prescribed perfectionism
Predicting chronic hypomanic/biphasic symptoms
DAS: goal attainment factor
MPS: self-oriented perfectionism
MPS: socially-prescribed perfectionism
In the two mediation models where chronic hypomanic
symptoms were the dependent variables,
socially-prescribed perfectionism mediated the relationship between
both anxiety and stress symptoms and chronic
hypomanic symptoms. For anxiety symptoms, the true
indirect effects were estimated to lie between 0.07 and 0.26.
For stress symptoms, the true indirect effects were
estimated to lie between 0.08 and 0.27. Self-oriented
perfectionism was not a significant mediator.
Separate analyses for probands and non-affected
family members are available in the supplementary analysis
(see Additional file 1: Tables S1, S2). As the results
replicate the combined sample, they were not included in the
main results of this paper. The results in both groups are
consistent with the combined sample with only
self-oriented perfectionism significantly mediating the
relationship between anxiety and stress symptoms and chronic
depressive symptoms. For hypomanic symptoms, only
socially-prescribed perfectionism significantly mediated
the relationship between anxiety and stress symptoms
and chronic hypomanic symptoms.
The results highlight the potential role of perfectionism
as a mechanism explaining the co-occurrence between
BD and anxiety. The results further suggest that
different dimensions of perfectionism are uniquely associated
with chronic depressive and (hypo)manic symptoms.
Univariate associations between self- and
socially-prescribed perfectionism and BD symptomatology were
consistent with previous reports
(Lam et al. 2004; Hewitt
et al. 1998)
. Similarly, we confirmed significant
relationships between both self- and socially-prescribed
perfectionism and anxiety and stress symptoms
et al. 2011)
. Like Hewitt
(Hewitt et al. 1998)
, we found
that self-oriented perfectionism was uniquely associated
with chronic depressive symptoms after controlling for
chronic (hypo)manic symptoms; this suggests a
preoccupation with high standards for oneself and a punitive
response when mistakes are made, or when
perfectionistic standards are not met. Previous studies have found
self-oriented perfectionism to be associated with
unipolar depressive symptoms
(Hewitt and Flett 1993; Hewitt
et al. 1996)
and there are similarities between the
cognitive styles of unipolar and bipolar depression (Scott and
Pope 2003). The particular relevance of self-oriented
perfectionism for depression (versus socially-prescribed
perfectionism) is consistent with research
highlighting the role of ruminative, self-focused attention in the
onset and maintenance of depression
1991, 2000; Kuehner and Weber 1999)
self-focus has been found to influence global negative
self-judgments (e.g. “I am a failure”) which increases
(Rimes and Watkins 2005)
For hypomanic symptoms, our findings suggest that
an interpersonal focus is more important given that
socially-prescribed perfectionism is defined as
perceiving that others hold excessively high standards for
oneself. We found that socially-prescribed perfectionism was
uniquely associated with chronic (hypo)manic symptoms
after controlling for chronic depressive symptoms. This
is consistent with Shepero et al’s
(Shapero et al. 2015)
finding that higher public self-consciousness
(reflecting a person’s awareness of other’s view of themselves)
distinguished BD patients from those with MDD (along
with higher rumination on positive affect)
et al. 2015)
. Socially-prescribed perfectionism is also
considered to be more maladaptive than self-oriented
perfectionism, with self-criticism being the most
(Blankstein and Dunkley 2002)
. In a
sample of individuals with BD-II and cyclothymia, Alloy
et al. found that higher autonomy (a construct related to
perfectionism) and self-criticism predicted a greater
likelihood of (hypo)manic episodes over 3.2 year follow-up
(Alloy et al. 2009b)
. Our findings strengthen the
hypothesis that a cognitive style characterized by a concern about
the negative perceptions of others is associated with
The second aim of our study was to examine whether
perfectionism mediates the relationship between stress
and anxiety symptoms and BD symptoms in an attempt
to understand mechanisms underlying the high
comorbidity between anxiety symptoms and BD. For chronic
bipolar depressive symptoms, the mediation models
were significant with self-orientated perfectionism found
to significantly mediate the relationship between
anxiety and stress symptoms and bipolar depressive
symptoms. These findings remained after controlling for the
presence of chronic (hypo)manic symptoms. These
findings are consistent with our previous finding in a clinical
(Corry et al. 2013)
. Our hypothesis that
sociallyprescribed perfectionism and goal attainment values
would mediate the relationship between anxiety and
stress symptoms and chronic hypomanic symptoms was
partially supported. Only socially-prescribed
perfectionism (not goal attainment values) was uniquely associated
with chronic hypomanic symptoms in the linear
regression models in the current study; therefore, we considered
only socially-prescribed perfectionism in the mediation
models. In mediation models, socially-prescribed
perfectionism significantly mediated associations between both
anxiety and stress, and chronic hypomanic symptoms
after controlling for the presence of chronic depressive
symptoms. This finding is inconsistent with our previous
study and likely represents methodological differences in
the measurement of (hypo)mania (chronic in the present
study versus current in our previous study)
(Corry et al.
. It is important to note that the present findings do
not imply that perfectionism is the only mediator between
anxiety and stress symptoms and bipolar disorder
symptoms. Perfectionism is only a partial mediator in the
mediation models, leaving room for other constructs to
play a role. For example, the perfectionism literature also
highlights the importance of coping styles, emotional
regulation strategies and congruent life events to explain the
relationship between perfectionism and psychopathology
(Dunkley and Blankstein 2000; Dunkley et al. 2003)
Our findings are consistent with current cognitive,
transdiagnostic models of BD. Specifically, that
self-critical, perfectionistic beliefs are related to both
depressive and (hypo)manic symptoms
(see Mansell et al. 2007;
and that anxiety is likely a precursor to
depressive symptoms in BD (Holmes et al. 2008).
Consistent with Mansell et al.’s and Holmes’ model it is
proposed that depressive and/or (hypo)manic symptoms
arise from the use of unhelpful emotional regulation
strategies (ascent and descent behaviours) in response
to anxiety and stress symptoms driven by perfectionistic
and/or goal attainment beliefs [see
illustrative case formulation],
(Holmes et al. 2008;
Mansell et al. 2007)
. A key component of Mansell’s model, the
conflicted appraisals of an individual’s internal state, was
not examined here, but would be crucial in further
understanding the transition from stress and anxiety symptoms
to depressive and (hypo)manic symptoms. The role that
perfectionism may play in these appraisals also warrants
further investigation. It may be that anxiety/stress and
depression are not merely co-occurring emotional states
(or comorbid disorders) but that there is a dynamic,
iterative process that occurs within an individual that
sometimes produces a predominantly anxious presentation
(i.e. meeting criteria for an anxiety disorder) and at other
times produces symptoms consistent with a formal mood
proposes that the
manner in which mood fluctuations express themselves over
time should determine the diagnosis and that the nature
of current symptoms will be a complex result of: (1)
experiencing previous vicious cycles; (2) the nature of the
underlying beliefs; and (3) the current environment.
The presence of these significant relationships in the
current sample, comprising both affected and unaffected
relatives within affected families, suggests that these
processes are operating outside of formal episodes and may
represent intermediate phenotypes in those at genetic
risk of developing either depressive or (hypo)manic
episodes. Perfectionism has been proposed to have
(Flett et al. 2002)
, with maternal criticism
when standards are not met
(Bleys et al. 2016; Greblo and
and parental psychological control found
to be particularly important
(Soenens et al. 2005)
findings are also consistent with perfectionism being a
transdiagnostic psychological risk factor for
(Bieling et al. 2004; Egan et al. 2011)
BD, previous research suggests that family socialization
plays a role in shaping beliefs towards goal attainment
and achievement that conveys a vulnerability to
developing the cognitions that are characteristic of (hypo)mania
(Chen and Johnson 2012)
. Given that the presence of
perfectionistic cognitions and anxiety/stress symptoms
may be necessary but not the whole picture of risk for
experiencing BD symptoms, future research is necessary
to better understand what additional risk factors are
present that give rise to BD symptomatology against a
background of familial risk.
A number of limitations in this study are important
to acknowledge. Firstly, the cross-sectional nature of
the study means that caution must be exercised when
inferring causality. Ultimately longitudinal data will be
required to more definitively investigate relationships
between perfectionism, anxiety/stress, and mood
symptom development over time. The cross-sectional nature
of the study also makes it impossible to be certain about
the directionality of the relationship between the
variables of interest. However, our hypotheses are proposed
on the basis of other studies that have used longitudinal
designs and have attained similar results
et al. 2015; Alloy et al. 2009b)
. Secondly, the present study
examined anxiety (and stress) symptoms dimensionally
rather than using formal categorical diagnostic criteria;
to better understand issues of comorbidity with BD, it
will be useful to examine these relationships among
people with specific categorical anxiety diagnoses, such as
those defined by DSM-5. Thirdly, anxiety has been found
to influence the course of bipolar disorder in other ways.
Higher likelihood of relapse
(Otto et al. 2006)
(Dilsaver et al. 2006; Young et al. 1993)
and greater number of episodes (Bauer et al. 2005) have
all been found to be increased in those with comorbid BD
and anxiety disorders compared to those with BD only.
While beyond the scope of the current study it would
be useful to examine the role of perfectionism
mediating the relationship between anxiety and other markers
of BD severity. For example, people with BD who exhibit
a cognitive style characterized by rigidity and pessimism
are less likely to recover from their BD depressive episode
or, if able to recover, take longer to do so
(Stange et al.
. Additionally, we did not measure the occurrence
of life events in the current study. The
cognitive-diathesis stress model of psychopathology proposes that
negative cognitive styles or schemas interact with life events
to trigger symptoms of psychopathology
; specific life events associated with achievement
may be particularly relevant to the development of mood
episodes in BD
(Alloy et al. 2005; Koenders et al. 2014)
Lastly, the variables of interest were assessed using
retrospective, self-report measures and it therefore it could be
argued that responses are unduly influenced by the
current mood state of the participants. Future research using
experience-sampling methodology would enable the
relationships between anxiety and stress symptoms,
perfectionism and BD symptoms to be more clearly elucidated.
In sum, this study provides support for the role of
perfectionism in the co-occurrence of anxiety, stress, depression
and (hypo)manic symptoms in BD. There are promising
treatments for clinical perfectionism
(Egan et al. 2014)
and also transdiagnostic approaches to targeting both
anxiety and BD symptoms
(Ellard et al. 2012)
be useful in psychological treatment approaches. These
findings further suggest that BD patients and/or those
considered at risk of BD should be routinely screened
for the presence of maladaptive perfectionism and
considered for the need for psychological intervention to
address anxiety, depressive and (hypo)manic symptoms,
in addition to appropriate pharmacotherapy.
Additional file 1. Supplementary separate analyses for probands and
non-affected family members.
JC: Conception and design of the study; data analysis and interpretation,
drafting of the article, critical revision of the article, final approval of the version to
be published. MG: Data analysis and interpretation, drafting of the article, final
approval of the version to be published. GR: Data analysis and interpretation,
critical revision of the article, final approval of the version to be published. JF:
Conception and design of the study, data collection, critical revision of the
article, final approval of the version to be published. PS: Data analysis and
interpretation, critical revision of the article, final approval of the version to be
published. PM: Conception and design of the study, data analysis and
interpretation, drafting of the article, critical revision of the article, final approval of the
version to be published. All authors read and approved the final manuscript.
We thank Dusan Hadzi-Pavlovic for his contribution to data analysis.
The authors declare that they have no competing interests.
Availability of data and materials
The data will not be shared or made publicly available. Informed consent for
this was not sought from the study participants prior to the collection of data.
Consent for publication
Ethical approval and consent to participate
This study was approved by the Human Research Ethics Committee of the
University of New South Wales, Sydney, Australia. All subjects gave written
This study was funded by an Australian National Health and Medical Research
Council (NHMRC) Program Grant Number 1037196. MJG was funded by
the NHMRC’s R.D. Wright Biomedical Career Development Fellowship
(APP108187). The funding bodies acknowledged above had not role in the
design of the study, collection and analysis of data, or the decision to publish.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Alloy LB , Abramson LY , Urosevic S , Walshaw PD , Nusslock R , Neeren AM . The psychosocial context of bipolar disorder: environmental, cognitive, and developmental risk factors . Clin Psychol Rev . 2005 ; 25 : 1043 - 75 .
Alloy LB , Abramson LY , Walshaw PD , Keyser J , Gerstein RK . A cognitive vulnerability-stress perspective on bipolar spectrum disorders in a normative adolescent brain, cognitive, and emotional development context . Dev Psychopathol . 2006 ; 18 ( 4 ): 1055 - 103 .
Alloy LB , Abramson LY , Flynn M , Liu RT , Grant DA , Jager-Hyman S , et al. Selffocused Cognitive Styles and Bipolar Spectrum Disorders: concurrent and Prospective Associations . Int J cognit Ther. 2009a;2 ( 4 ): 354 .
Alloy LB , Abramson LY , Walshaw PD , Gerstein RK , Keyser JD , Whitehouse WG , et al. Behavioral approach system (BAS)-relevant cognitive styles and bipolar spectrum disorders: concurrent and prospective associations . J Abnorm Psychol. 2009b;118 ( 3 ): 459 - 71 .
Antony MM , Purdon CL , Huta V , Swinson RP . Dimensions of perfectionism across the anxiety disorders . Behav Res Ther . 1998 ; 36 ( 12 ): 1143 - 54 .
Bauer S , Crits-Christoph P , Ball WA , Dewees E , McAllister T , Alahi P , et al. Independent assessment of manic and depressive symptoms by self-rating: scale characteristics and implications for the study of mania . Arch Gen Psychiatry . 1991 ; 48 : 807 - 12 .
Bauer MS , Vojta C , Kinosian B , Altshuler L , Glick H. The Internal State Scale: replication of its discriminating abilities in a multisite, public sector sample . Bipolar Disord . 2000 ; 2 : 340 - 6 .
Bauer MS , Altshuler L , Evans DR , Beresford T , Williford WO , Hauger R . Prevalence and distinct correlates of anxiety, substance, and combined comorbidity in a multi-site public sector sample with bipolar disorder . J Affect Disord . 2005 ; 85 ( 3 ): 301 - 15 .
Beck AT . Depression: clinical, experimental and clinical aspects . New York: Harper and Row; 1967 .
Beck AT. Cognitive Therapy and the Emotional Disorders . New York: International Universities Press; 1976 .
Beck AT , Rush AJ , Shaw BF , Emery G. Cognitive Therapy of Depression . New York: Guilford Press; 1979 .
Bieling PJ , Summerfeldt LJ , Israeli AL , Antony MM . Perfectionism as an explanatory construct in comorbidity of axis I disorders . J Psychopathol Behav Assess . 2004 ; 26 : 193 - 201 .
Blankstein KR , Dunkley DM . Evaluative concerns, self-critical, and personal standards perfectionism: A structural equation modeling strategy . In: Flett DL , Hewitt PL , editors. Perfectionism: Theory , research and treatment. Washington, DC: American Psychological Association; 2002 . p. 285 - 315 .
Bleys D , Soenens B , Boone L , Claes S , Vliegen N , Luyten P. The role of intergenerational similarity and parenting in adolescent self-criticism: an actorpartner interdependence model . J Adolesc . 2016 ; 49 : 68 - 76 .
Boylan KR , Begin H , Young LT , Bieling PJ , Marriott M , MacQueen GM . Impact of comorbid anxiety disorders on outcome in a cohort of patients with bipolar disorder . J Clin Psychiatry . 2004 ; 65 ( 8 ): 1106 - 13 .
Chang EC . Perfectionism as a predictor of positive and negative psychological outcomes: examining a mediation model in younger and older adults . J Couns Psychol . 2000 ; 47 : 18 - 26 .
Chen SH , Johnson SL . Family influences on mania-relevant cognitions and beliefs: a cognitive model of mania and reward . J Clin Psychol . 2012 ; 68 ( 7 ): 829 - 42 .
Corry J , Green M , Roberts G , Frankland A , Wright A , Lau P , et al. Anxiety, stress and perfectionism in bipolar disorder . J Affect Disord . 2013 ; 151 ( 3 ): 1016 - 24 .
de Graaf R , Bijl RV , Spijker J , Beekman AT , Vollebergh WA . Temporal sequencing of lifetime mood disorders in relation to comorbid anxiety and substance use disorders-findings from the Netherlands Mental Health Survey and Incidence Study . Soc Psychiatry Psychiatr Epidemiol . 2003 ; 38 ( 1 ): 1 - 11 .
Depue RA , Slater JF , Wolfstetter-Kausch H , Klein D , Goplerud E , Farr D. A behavioral paradigm for identifying persons at risk for bipolar depressive disorder: a conceptual framework and five validation studies . J Abnorm Psychol . 1981 ; 90 ( 5 ): 381 - 437 .
Depue RA , Krauss S , Spoont MR , Arbisi P. General Behaviour Inventory identification of unipolar and bipolar affective conditions in a nonclinical university population . J Abnorm Psychol . 1989 ; 98 : 117 - 26 .
Dilsaver SC , Akiskal HS , Akiskal KK , Benazzi F . Dose-response relationship between number of comorbid anxiety disorders in adolescent bipolar/ unipolar disorders, and psychosis, suicidality, substance abuse and familiality . J Affect Disord . 2006 ; 96 ( 3 ): 249 - 58 .
Dunkley DM , Blankstein KR . Self-critical perfectionism, coping, hassles and current distress: a structural equation modeling approach . Cognit Ther Res . 2000 ; 24 : 713 - 30 .
Dunkley DM , Zuroff DC , Blankstein KR . Self-critical perfectionism and daily affect: dispositional and situational influences on stress and coping . J Pers Soc Psychol . 2003 ; 84 : 234 - 52 .
Egan SJ , Wade TD , Shafran R . Perfectionism as a transdiagnostic process: a clinic review . Clin Psychol Rev . 2011 ; 31 : 203 - 12 .
Egan SJ , van Noort E , Chee A , Kane RT , Hoiles KJ , Shafran R , et al. A randomised controlled trial of face to face versus pure online self-help cognitive behavioural treatment for perfectionism . Behav Res Ther . 2014 ; 63 : 107 - 13 .
Ellard KK , Deckersbach T , Sylvia LG , Nierenberg AA , Barlow DH . Transdiagnostic treatment of bipolar disorder with comorbid anxiety with the unified protocol: a clinical replication series . Behav Modif . 2012 ; 36 ( 4 ): 482 - 508 .
Flett GL , Hewitt PL , Endler NS , Tassone C . Perfectionism and components of state and trait anxiety . Curr Psychol Dev Learn Personal Soc . 1995 ; 13 ( 4 ): 326 - 50 .
Flett GL , Hewitt PL , Oliver JM , Macdonald S . Perfectionism in children and their parents: a developmental analysis . Perfectionism: theory, research and treatment. Washington, D.C.: American Psychological Association; 2002 . p. 89 - 132 .
Francis-Raniere EL , Alloy LB , Abramson LY . Depressive personality styles and bipolar spectrum disorders: prospective tests of the event congruency hypothesis . Bipolar Disord . 2006 ; 8 : 382 - 99 .
Frost RO , DiBartolo PM . Perfectionism, anxiety, and obsessive-compulsive disorder . In: Flett DL , Hewitt PL , editors. Perfectionism: theory research and treatment. Washington, DC: American Psychological Association; 2002 . p. 341 - 71 .
Fullerton JM , Donald JA , Mitchell PB , Schofield PR . Two-dimensional genome scan identifies multiple genetic interactions in bipolar affective disorder . Biol Psychiatry . 2010 ; 67 ( 5 ): 478 - 86 .
Gershon ES , Hamovit J , Guroff JJ , Dibble E , Leckman JF , Sceery W , et al. A family study of schizoaffective, bipolar I, bipolar II, unipolar, and normal control probands . Arch Gen Psychiatry . 1982 ; 39 ( 10 ): 1157 - 67 .
Glick H , McBride L , Bauer MS . A manic-depressive symptom self-report in optical scanable format . Bipolar Disord . 2003 ; 5 : 366 - 9 .
Greblo Z , Bratko D. Parents' perfectionism and its relation to child rearing behaviors . Scand J Psychol . 2014 ; 55 : 180 - 5 .
Harvey AG , Watkins E , Mansell W , Shafran R . Cognitive behavioural processes accross the psychological disorders. A transdiagnostic approach to research and treatment . Oxford: Oxford University Press; 2004 .
Hewitt PL , Flett DL . Perfectionism in the self and social contexts: conceptualisation, assessment and association with psychopathology . J Pers Soc Psychol . 1991 ; 60 ( 3 ): 456 - 70 .
Hewitt PL , Flett GL . Dimensions of perfectionism, daily stress, and depression: a test of the specific vulnerability hypothesis . J Abnorm Psychol . 1993 ; 102 ( 1 ): 58 - 65 .
Hewitt PL , Flett GL . Perfectionism and stress processes in psychopathology . In: Flett GL , Hewitt PL , editors. Perfectionism: theory, research and treatment. Washington: American Psychological Association; 2002 . p. 255 - 84 .
Hewitt PL , Flett GL , Turnbull-Donovan W , Mikail SF . The Multidimensional Perfectionism Scale: reliability, validity, and psychometric properties in psychiatric samples . Psychol Assess . 1991 ; 3 ( 3 ): 464 - 8 .
Hewitt PL , Flett GL , Ediger E . Perfectionism and depression: longitudinal assessment of a specific vulnerability hypothesis . J Abnorm Psychol . 1996 ; 105 : 276 - 80 .
Hewitt PL , Flett GL , Ediger E , Norton GR , Flynn CA. Perfectionism in chronic and state symptoms of depression . Can J Behav Sci . 1998 ; 30 ( 4 ): 234 - 42 .
Holmes EA , Geddes JR , Colom F , Goodwin GM . Mental imagery as an emotional amplifier: application to bipolar disorder . Behav Res Ther . 2008 ; 46 : 1251 - 8 .
Johnson SL . Mania and dysregulation in goal pursuit: a review . Clin Psychol Rev . 2005 ; 25 : 241 - 62 .
Jones SH , Bentall R. A review of potential cognitive and environmental risk markers in children of bipolar parents . Clin Psychol Rev . 2008 ; 28 : 1083 - 95 .
Juster HR , Heimberg RG , Frost RO , Holt CS , Mattia JI , Faccenda K. Social phobia and perfectionism . Personal Individ Differ . 1996 ; 21 : 403 - 10 .
Koenders MA , Giltay EJ , Spijker AT , Hoencamp E , Spinhoven P , Elzinga BM . Stressful life events in bipolar I and II disorder: cause or consequence of mood symptoms? J Affect Disord . 2014 ; 161 : 55 - 64 .
Kuehner C , Weber I . Responses to depression in unipolar depressed patients: an investigation of Nolen-Hoeksema's response styles theory . Psychol Med . 1999 ; 29 ( 6 ): 1323 - 33 .
Lam D , Wright K , Smith N . Dysfunctional assumptions in bipolar disorder . J Affec Disord . 2004 ; 79 ( 1-3 ): 193 - 9 .
Lovibond SH , Lovibond PF . Manual for the Depression Anxiety Stress Scales . Sydney: Psychological Foundation Monograph; 1995a.
Lovibond PF , Lovibond SH . The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories . Behav Res Ther. 1995b;33 ( 3 ): 335 - 43 .
Mansell W. An integrative formulation-based cognitive treatment of bipolar disorders: application and illustration . J Clin Psychol . 2007 ; 63 ( 5 ): 447 - 61 .
Mansell W , Pedley R. The ascent into mania: a review of psychological processes associated with the development of manic symptoms . Clin Psychol Rev . 2008 ; 28 ( 3 ): 494 - 520 .
Mansell W , Morrison AP , Reid G , Lowens I , Tai S. The interpretation of, and responses to, changes in internal states: an integrative cognitive model of mood swings and bipolar disorders . Behav cognit Psychother . 2007 ; 35 : 515 - 39 .
McAuley EZ , Blair IP , Liu Z , Fullerton JM , Scimone A , Van Herten M , et al. A genome screen of 35 bipolar affective disorder pedigrees provides significant evidence for a susceptibility locus on chromosome 15q25-26 . Mol psychiatry . 2009 ; 14 ( 5 ): 492 - 500 .
McGuffin P , Rijsdijk F , Andrew M , Sham P , Katz R , Cardno A . The heritability of bipolar affective disorder and the genetic relationship to unipolar depression . Arch Gen Psychiatry . 2003 ; 60 ( 5 ): 497 - 502 .
Merikangas KR , Chakravarti A , Moldin SO , Araj H , Blangero JC , Burmeister M , et al. Future of genetics of mood disorders research . Biol Psychiatry . 2002 ; 52 ( 6 ): 457 - 77 .
Merikangas KR , Cui L , Heaton L , Nakamura E , Roca C , Ding J , et al. Independence of familial transmission of mania and depression: results of the NIMH family study of affective spectrum disorders . Mol Psychiatry . 2014 ; 19 ( 2 ): 214 - 9 .
Mitchell PB . Bipolar disorder and anxiety: a comorbidity needing better treatments . Lancet Psychiatry . 2015 ; 2 ( 8 ): 671 - 2 .
Muthén LK , Muthén BO . Mplus User's Guide, 8th Edition . Los Angeles: Muthén & Muthén; 1998 - 2017 .
Nolen-Hoeksema S . Responses to depression and their effects on the duration of depressed mood . J Abnorm Psychol . 1991 ; 100 : 569 - 82 .
Nolen-Hoeksema S . The role of rumination in depressive disorders and mixed anxiety/depressive symptoms . J Abnorm Psychol . 2000 ; 109 ( 3 ): 504 - 11 .
Nurnberger JI Jr, Blehar MC , Kaufmann CA , York-Cooler C , Simpson SG , Harkavy-Friedman J , et al. Diagnostic interview for genetic studies. Rationale, unique features, and training . NIMH Genetics Initiative. Arch Gen Psychiatry . 1994 ; 51 ( 11 ): 849 - 59 .
Nurnberger JI Jr, McInnis M , Reich W , Kastelic E , Wilcox HC , Glowinski A , et al. A high-risk study of bipolar disorder. Childhood clinical phenotypes as precursors of major mood disorders . Arch Gen Psychiatry . 2011 ; 68 ( 10 ): 1012 - 20 .
O'Garro-Moore JK , Adams AM , Abramson LY , Alloy LB . Anxiety comorbidity in bipolar spectrum disorders: the mediational role of perfectionism in prospective depressive symptoms . J Affect Disord . 2015 ; 174 : 180 - 7 .
Otto MW , Simon NM , Wisniewski SR , Miklowitz DJ , Kogan JN , Reilly-Harrington NA , et al. Prospective 12-month course of bipolar disorder in outpatients with and without comorbid anxiety disorders . Br J Psychiatry . 2006 ; 189 : 20 - 5 .
Pavlova B , Perlis RH , Alda M , Uher R . Lifetime prevalence of anxiety disorders in people with bipolar disorder: a systematic review and meta-analysis . Lancet Psychiatry . 2015 ; 2 ( 8 ): 710 - 7 .
Perich T , Lau P , Hadzi-Pavlovic D , Roberts G , Frankland A , Wright A , et al. What clinical features precede the onset of bipolar disorder? J Psychiatr Res . 2015 ; 62 : 71 - 7 .
Perugi G , Akiskal HS , Toni C , Simonini E , Gemignani A . The temporal relationship between anxiety disorders and (hypo)mania: a retrospective examination of 63 panic, social phobic and obsessive-compulsive patients with comorbid bipolar disorder . J Affect Disord . 2001 ; 1-3 : 199 - 206 .
Provencher MD , Guimond AJ , Hawke LD . Comorbid anxiety in bipolar spectrum disorders: a neglected research and treatment issue? J Affect Disord. 2012 ; 137 ( 1-3 ): 161 - 4 .
Rimes KA , Watkins E. The effects of self-focused rumination on global negative self-judgements in depression . Behav Res Ther . 2005 ; 43 ( 12 ): 1673 - 81 .
Scott J , Pope M. Cognitive styles in individuals with bipolar disorders . Psychol Med . 2003 ; 6 : 1081 - 8 .
Scott J , Stanton B , Garland A , Ferrier IN . Cognitive vulnerability in patients with bipolar disorder . Psychol Med . 2000 ; 30 ( 2 ): 467 - 72 .
Shapero BG , Stange JP , Goldstein KE , Black CL , Molz AR , Hamlat EJ , et al. Cognitive Styles in Mood Disorders: discriminative Ability of Unipolar and Bipolar Cognitive Profiles . Int J Cognit Ther . 2015 ; 8 ( 1 ): 35 - 60 .
Soenens B , Elliot AJ , Goossens L , Vansteenkiste M , Luyten P , Duriez B. The intergenerational transmission of perfectionism: parents' psychological control as an intervening variable . J Fam Psychol . 2005 ; 19 ( 3 ): 358 - 66 .
Stange JP , Sylvia LG , da Silva Magalhaes PV , Miklowitz DJ , Otto MW , Frank E , et al. Extreme attributions predict the course of bipolar depression: results from the STEP-BD randomized controlled trial of psychosocial treatment . J Clin Psychiatry . 2013 ; 74 ( 3 ): 249 - 55 .
Tabachnick BG , Fidell LS . Using Multivariate Statistics. 6th ed. MA: Allyn & Bacon; 2013 .
Weissman AN , Beck AT . Development and validation of the Dysfunctional Attitude Scale: a preliminary investigation . In: Paper presented at the 62nd annual meeting of the American educational research association , Toronto, Canada. Washington, DC: ERIC Clearinghouse; 1978 . http://www. eric.ed.gov/contentdelivery/serviet/ERICServiet?accno= ED167619 .
Wheeler HA , Blankstein KR , Antony MM , McCabe RE , Bieling PJ . Perfectionism in anxiety and depression: comparisons across disorders, relations with symptoms severity, and role of comorbidity . Int J Cognit Psychother . 2011 ; 4 : 66 - 91 .
Wirtz PH , Elsenbruch S , Emini L , Rudisuli K , Groessbauer S , Ehlert U . Perfectionism and the cortisol response to psychosocial stress in men . Psychosom Med . 2007 ; 69 ( 3 ): 249 - 55 .
Young LT , Cooke RG , Robb JC , Levitt AJ , Joffe RT . Anxious and non-anxious bipolar disorder . J Affect Disord . 1993 ; 29 ( 1 ): 49 - 52 .
Youngstrom EA , Murray G , Johnson SL , Findling RL . The 7 up 7 down inventory: a 14-item measure of manic and depressive tendencies carved from the General Behavior Inventory . Psychol Assess . 2013 ; 25 ( 4 ): 1377 - 83 .