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Perfectionism can become a debilitating condition that may negatively affect functioning in multiple areas, including mental health. Prior research has indicated that internet-based cognitive behavioral therapy can be beneficial, but few studies have included follow-up data.
The objective of this study was to explore the outcomes at follow-up of internet-based cognitive behavioral therapy with guided self-help, delivered as 2 separate randomized controlled trials conducted in Sweden and the United Kingdom.
In total, 120 participants randomly assigned to internet-based cognitive behavioral therapy were included in both intention-to-treat and completer analyses: 78 in the Swedish trial and 62 in the UK trial. The primary outcome measure was the Frost Multidimensional Perfectionism Scale, Concern over Mistakes subscale (FMPS CM). Secondary outcome measures varied between the trials and consisted of the Clinical Perfectionism Questionnaire (CPQ; both trials), the 9-item Patient Health Questionnaire (PHQ-9; Swedish trial), the 7-item Generalized Anxiety Disorder scale (GAD-7; Swedish trial), and the 21-item Depression Anxiety Stress Scale (DASS-21; UK trial). Follow-up occurred after 6 months for the UK trial and after 12 months for the Swedish trial.
Analysis of covariance revealed a significant difference between pretreatment and follow-up in both studies. Intention-to-treat within-group Cohen
The results are promising for the use of internet-based cognitive behavioral therapy as a way of targeting perfectionism, but the findings need to be replicated and include a comparison condition.
Perfectionism has many positive features, such as striving for excellence, but it can also have a negative impact in many areas, including mental health [
A systematic review and meta-analysis by Lloyd et al [
To extend the understanding of the treatment of perfectionism and to evaluate the efficacy of internet-based CBT (ICBT), 2 clinical trials of treatment with guided self-help were conducted in Sweden and the United Kingdom. The participants were self-referred and assigned to self-help with guidance from a therapist or to a waitlist control group. The results from pre- to posttreatment were encouraging, obtaining within-group Cohen
This study aimed to assess the long-term benefits of treating perfectionism by determining the outcomes at follow-up for those who received ICBT with guided self-help in the Swedish and UK studies. However, given the differences between the 2 clinical trials on several key characteristics, for example their inclusion and exclusion criteria, we present the results separately rather than combined.
Participants in both clinical trials consisted of self-referrals recruited through advertisements in the media, social media, and on campus grounds. Those interested in participating entered a website to complete a screening process and provide electronic informed consent. The websites were connected to a secure Web-based interface where self-report measures were presented, asynchronous communication with the study supervisors was carried out, and treatment content was delivered [
Individuals fulfilling the inclusion criteria and being deemed eligible to participate were randomly assigned to ICBT with guided self-help or to a waitlist control group. In total, 156 were included in the Swedish trial (guided self-help n=78), compared with 120 in the UK trial (guided self-help n=62). Those assigned to the waitlist control later received the same treatment content, either in a second wave of treatment (Swedish trial) or by being given a self-help book (UK trial); we did not consider these participants in this study. Further details regarding recruitment and eligibility can be obtained elsewhere [
The main outcome measure in both trials was the FMPS CM [
The secondary outcome measures differed between the 2 clinical trials but are nonetheless reported to examine the benefits on conditions other than perfectionism. In the Swedish trial, these were the 9-item Patient Health Questionnaire (PHQ-9) [
Key characteristics of the clinical trials. FMPS CM: Frost Multidimensional Perfectionism Scale, Concern over Mistakes subscale; SMS: short message service text messaging.
Characteristic | Swedish trial | UK trial | |
Recruitment process | Self-referrals | Self-referrals | |
Cutoff criteria for maladaptive perfectionism | No | Yes (≥29 on the FMPS CM) | |
Telephone interview assessment | Yes (Mini-International Neuropsychiatric Interview) | No | |
Minimum age | Yes (>18 years) | Yes (>18 years) | |
Concurrent psychological treatment | Not allowed | Allowed | |
Change in pharmacological treatmenta | Not allowed | Allowed | |
Other more severe conditions | Not allowed (eg, anorexia nervosa) | Allowed (except suicidality) | |
Randomization | Yes (once) | Yes (continuous) | |
Confirmation to commence treatment | Yes | No | |
Starting date | Simultaneous for all participants | Individual starting dates | |
Guidance from a therapist | Yes (on 2 predetermined weekdays) | Yes (weekly but with no specification) | |
Therapist level | Master’s degree | Mixed (undergraduate to PhD) | |
Therapist supervision | Yes (weekly) | Yes (monthly) | |
Feedback checked by supervisor | No | Yes | |
Treatment protocol | Egan et al [ |
Egan et al [ |
|
Treatment period | 8 weeks | 12 weeks | |
Follow-up | 12 months | 6 months | |
Follow-up reminders | Telephone, email, and SMS | ||
Monetary compensation | No | Yes (£10)c | |
Ethics approval | Yes (Dnr 2015/419-31) | Yes (project identifier 6222:001) | |
Study protocol | No | Yes [ |
|
Registered at ClinicalTrials.gov | No | Yes (registration no. NCT02756871) | |
Informed consent obtained | Yes | Yes |
aAny change 3 months prior to the screening process.
bMinor change in order of modules and greater emphasis on behavioral interventions.
cIf participant completed posttreatment assessment.
Flow of participants through the study. ICBT: Internet-based cognitive behavioral therapy; MINI: Mini-International Neuropsychiatric Interview.
Baseline characteristics of the participants at pretreatment assessments. FMPS CM: Frost Multidimensional Perfectionism Scale, Concern over Mistakes subscale; N/A: not applicable.
Baseline characteristic | UK trial (n=62) | Swedish trial (n=78) | χ2 | 95% CI | ||
Female sex, n (%) | 49 (79.0) | 64 (82.1) | 0.2 | 1 | N/A | |
Age (years), mean (SD) | 28.6 (8.3) | 34.22 (9.9)a | N/A | N/A | 2.6 to -8.7 | |
32.3 | 2 | N/A | ||||
Single | 48 (77.4)a | 23 (29.5) | ||||
Married/partner | 14 (22.6) | 52 (66.7)a | ||||
Divorced/widowed | 0 (0.0) | 3 (3.8) | ||||
Prior mental health problem (yes), n (%) | 20 (27.4) | 4 (5.1) | 17.9 | 1 | N/A | |
Psychological treatment (yes), n (%) | 16 (25.8)a | 0 (0) | 22.7 | 1 | N/A | |
Psychotropic medication (yes), n (%) | 11 (17.7)a | 5 (6.4) | 36.5 | 1 | N/A | |
FMPS CM | 36.7 (4.4)a | 33.4 (6.4) | N/A | N/A | 1.5 to 5.1 | |
Clinical Perfectionism Questionnaire | 35.7 (4.7) | 38.3 (4.6)a | N/A | N/A | –4.1 to –1.0 |
aThe clinical trial with significantly higher values on a specific baseline characteristic.
Modules and order of presentation in the clinical trials.
Module | Swedish trial | UK trial |
1 | Understanding your perfectionism | Understanding your perfectionism |
2 | Your own model, values, and motivation | Your own model, values, and motivation |
3 | Surveys and experiments | Surveys and experiments |
4 | Dealing with perfectionistic behaviors | New ways of thinking |
5 | New ways of thinking | Dealing with perfectionistic behaviors |
6 | Self-criticism and self-compassion | Self-criticism and self-compassion |
7 | Self-worth | Self-worth |
8 | Maintain and continue positive change | Maintain and continue positive change |
The outcome measures were completed at pre- and posttreatment and follow-up (12 months for the Swedish trial and 6 months for the UK trial). The CPQ was also distributed weekly during the treatment period for the UK trial.
In both clinical trials, the treatment content was derived from Egan et al [
Given the significant baseline differences between the 2 trials, as well as the different lengths of follow-up, we did not combine the data for any analyses. We calculated a priori power for the 2 clinical trials to detect significant differences compared with the waitlist control at posttreatment, but not for a between-study difference at follow-up. We explored differences between the Swedish and the UK trial at baseline, as well as baseline predictors of completion of the self-report measures at follow-up (ie, dropouts, regardless of the number of modules they had completed during the treatment period), by using 2-sided independent
We performed intention-to-treat analyses for the main and secondary outcome measures using multiple imputation to account for missing values and we conducted completer analyses using available data. The imputation models used all available self-report measures to create 10 imputed datasets. We then used analysis of covariance (ANCOVA) to investigate the change scores between pretreatment and follow-up, with scores at baseline as covariates, averaging the parameter estimates for the 10 analyses. All statistical analyses were done with IBM SPSS version 24.0.0.1 (IBM Corporation).
Using the results from the ANCOVAs, we calculated within-group effect sizes for the means of 2 assessments, divided by the pooled standard deviations. All results are presented with 95% CIs, where applicable, including effect sizes, and discussed in relation to similar findings in other clinical trials [
All presented results concern the 6- and 12-month follow-ups. For a review of the outcomes at posttreatment, see Rozental et al [
There was no statistical difference between the 2 clinical trials in attrition, defined as the number of participants who were randomly assigned but did not complete the assessment at follow-up. In the Swedish trial, 49 (63%) completed the follow-up self-report measures, compared with 35 (57%) in the UK trial (χ21=0.6,
The completer analyses revealed significant differences for both clinical trials between pretreatment and follow-up, revealing a mean difference of 8.98 points (Swedish trial; 95% CI 7.07-10.89) and 10.35 points (UK trial; 95% CI 7.25-13.44) for the FMPS CM. Results were similar for the CPQ: 8.69 points (Swedish trial; 95% CI 6.61-10.77) and 11.10 (UK trial; 95% CI 9.14-13.07). For the secondary outcome measures, the mean differences in the Swedish trial were 3.57 points for the PHQ-9 (95% CI 2.28-4.86) and 3.22 points for the GAD-7 (95% CI 2.33-4.12). In the UK trial, the mean difference for the DASS was 8.78 points (95% CI 4.16-13.40).
Observed and estimated scores for each primary outcome measure, by clinical trial, intention-to-treat analysis, and completer analysis. FMPS: Frost Multidimensional Perfectionism Scale, Concern over Mistakes subscale.
Measure and condition | Intention-to-treat analysis | Completer analysis | |||||||||||
Pretreatment | Follow-up | Pretreatment | Follow-up | ||||||||||
Mean (SD) | n | Mean (SD) | n | Mean (SD) | n | Mean (SD) | n | ||||||
FMPS CM | 33.42 (6.44) | 78 | 25.14 (7.23) | 78 | 33.42 (6.44) | 78 | 23.61 (7.60) | 49 | |||||
Clinical Perfectionism Questionnaire | 38.26 (4.63) | 78 | 29.63 (8.00) | 78 | 38.26 (4.63) | 78 | 29.51 (6.70) | 49 | |||||
9-item Patient Health Questionnaire | 9.59 (5.63) | 78 | 6.45 (4.73) | 78 | 9.59 (5.63) | 78 | 5.47 (4.77) | 49 | |||||
7-item Generalized Anxiety Disorder scale | 7.83 (4.85) | 78 | 4.95 (3.72) | 78 | 7.83 (4.85) | 78 | 3.84 (3.41) | 49 | |||||
FMPS CM | 36.71 (4.42) | 62 | 28.83 (7.80) | 62 | 36.71 (4.42) | 62 | 25.52 (8.07) | 29 | |||||
Clinical Perfectionism Questionnaire | 35.69 (4.73) | 62 | 27.25 (6.44) | 62 | 35.69 (4.73) | 62 | 24.55 (5.25) | 29 | |||||
21-item Depression Anxiety Stress Scale | 26.31 (12.82) | 62 | 19.89 (13.11) | 62 | 26.31 (12.82) | 62 | 15.93 (12.52) | 27 |
a12-month follow-up.
b6-month follow-up.
Within-group effect sizes, Cohen
Measure and condition | Intention-to-treat analysis | Completer analysis | |
Cohen |
Cohen |
||
FMPS CM | 1.21 (0.86-1.54) | 1.42 (1.01-1.81) | |
Clinical Perfectionism Questionnaire | 1.32 (0.97-1.66) | 1.59 (1.17-1.98) | |
9-item Patient Health Questionnaire | 0.60 (0.28-0.92) | 0.77 (0.40-1.14) | |
7-item Generalized Anxiety Disorder scale | 0.67 (0.34-0.99) | 0.92 (0.54-1.29) | |
FMPS CM | 1.24 (0.85-1.62) | 1.92 (1.38-2.43) | |
Clinical Perfectionism Questionnaire | 1.49 (1.09-1.88) | 2.27 (1.70-2.80) | |
21-item Depression Anxiety Stress Scale | 0.50 (0.13-0.85) | 0.82 (0.34-1.28) |
Recovery on the FMPS CM was defined as those participants having a score at follow-up within 1 SD of the general population (<29; ie, clinically significant change) and exceeding the RCI. According to this definition, 29/49 (59%) participants in the Swedish trial and 15/35 (43%) in the UK trial met the criteria for recovery at follow-up. Improvement—that is, having a change score beyond the RCI at follow-up—was achieved by 31/49 (63%) in the Swedish trial and 18/35 (51%) in the UK trial. Meanwhile, 17/49 (35%) in the Swedish trial and 11/35 (31%) in the UK trial did not respond. In none of these cases was there a significant difference between the 2 clinical trials: χ22 range 3.09 to 3.99,
This study evaluated the long-term benefits of ICBT with guided self-help for perfectionism, indicating that the results at follow-up were similar to and possibly even somewhat improved from posttreatment. This suggests that ICBT with guidance from a therapist could help individuals manage and overcome their perfectionism in the long term. Compared with the findings of Lloyd et al [
The rates of recovery at follow-up, that is, those participants meeting the criteria of moving from a dysfunctional to a functional distribution in terms of perfectionism (clinically significant change and exceeding the RCI) were 59% (FMPS CM) in the Swedish trial and 43% (FMPS CM) in the UK trial. This can be compared with the results of Egan et al [
This study makes an important contribution to the research on the treatment of perfectionism, as it is one of few studies that included follow-up data and the only one to date, to our knowledge, with follow-up at 12 months. There are, however, also limitations that need to be addressed. First, issues related to the design limit the conclusions that can be made. The 2 clinical trials differed on some key characteristics, including different length of the treatment period (8 vs 12 weeks), therapist experience, therapist supervision, and, especially, the timing of the follow-up assessment. This was primarily due to different conventions and logistical issues among the researchers involved, meaning that the samples could not be combined and thus limit power. Nevertheless, given the many similarities between them in terms of treatment content and delivery, the findings are arguably relevant to present together. Additionally, there was no comparison group. However, replicating this study is warranted, possibly by recruiting a larger and more heterogeneous sample in the context of a randomized controlled trial.
Second, attrition was high in both clinical trials, with only 63% (Swedish trial) and 57% (UK trial) completing the self-report measures at 6- and 12-month follow-up, respectively, potentially affecting the conclusions that can be drawn. This can be compared with a study on ICBT for procrastination [
Third, perfectionism is not a psychiatric disorder in itself [
Fourth, the participants in this study were all self-referred, and although they scored high on perfectionism at pretreatment, they may not be representative of individuals with this problem in general. Arnberg et al [
We examined the long-term benefits of ICBT with guided self-help for perfectionism, depression, and anxiety. The results at follow-up were comparable with posttreatment assessment, obtaining medium to large within-group effect sizes. The results from these 2 different cases of ICBT with guided self-help are thus promising but warrant replication using a larger and more heterogeneous sample.
analysis of covariance
cognitive behavioral therapy
Clinical Perfectionism Questionnaire
21-item Depression Anxiety Stress Scale
Frost Multidimensional Perfectionism Scale, Concern over Mistakes subscale
internet-based cognitive behavioral therapy
9-item Patient Health Questionnaire
Reliable Change Index
The authors would like to acknowledge Linköping University and a Professor’s grant to the Principal Investigator (GA), which made the completion of the study possible. The study was also supported by the National Institute for Health Research Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and University College London. Further, we thank George Vlaescu for his outstanding webmaster service, and Chloe Shu for providing the basis for the original website for the study.
None declared.