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Self-Critical Perfectionism and Depression Maintenance Over One Year: The

Moderating Roles of Daily Stress-Sadness Reactivity and the Cortisol Awakening
Response

Article  in  Journal of Counseling Psychology · January 2018

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Running head: PERFECTIONISM, STRESS, AND DEPRESSION 1

In press. Journal of Counseling Psychology.

Self-Critical Perfectionism and Depression Maintenance Over One Year: The Moderating Roles

of Daily Stress-Sadness Reactivity and the Cortisol Awakening Response

Tobey Mandel and David M. Dunkley Maxim Lewkowski

Lady Davis Institute - Jewish General Hospital McGill University
McGill University McGill University Health Centre

David C. Zuroff Sonia J. Lupien

McGill University Université de Montréal

Robert-Paul Juster N. M. K. Ng Ying Kin

Columbia University Medical Center McGill University
Douglas Hospital Research Centre

J. Elizabeth Foley Gail Myhr

Lady Davis Institute - Jewish General Hospital McGill University
McGill University McGill University Health Center

Ruta Westreich†
Lady Davis Institute - Jewish General Hospital
McGill University

© 2018, American Psychological Association. This paper is not the copy of record and may
not exactly replicate the final, authoritative version of the article. Please do not copy or cite
without authors permission. The final article will be available, upon publication, via its
DOI: 10.1037/cou0000284
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 2

Author Note:

Please address correspondence to Tobey Mandel at Jewish General Hospital, Institute of

Community and Family Psychiatry, 4333 Côte Ste-Catherine Road, Montreal, Quebec, H3T 1E4

(Telephone: 514-340-8210; Fax: 514-340-8124; E-mail: tobey.mandel@mail.mcgill.ca).

Acknowledgements:

This research was supported by a Fonds de la Recherche en Santé du Québec Grant (David M.

Dunkley, David C. Zuroff, Sonia J. Lupien, N. M. K. Ng Ying Kin, Gail Myhr, Ruta Westreich),

Bourses de Chercheurs-Boursiers (David M. Dunkley), Douglas Utting Fellowships for Studies

in Depression (Maxim Lewkowski, Elizabeth Foley), and a FQRSC Doctoral Fellowship (Tobey

Mandel). None of the funding organizations had any role in the design and conduct of the study;

in the collection or interpretation of the data; nor in the writing of the report or in the decision to

submit it. We are very grateful to two Master’s students, Jody-Lynn Berg and Denise Ma, for

help in the collection of the data. The authors report that there are no conflicts of interest.
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 3

Abstract

This study of depressed outpatients (N = 43) examined daily stress-sadness reactivity and

the cortisol awakening response (CAR) as moderators of the relationship between self-critical

(SC) perfectionism and depression over one year. Participants completed perfectionism measures

at baseline (Time 1), daily diaries and salivary sampling six months later (Time 2), and an

interviewer-rated depression measure at Time 1, Time 2, and one year after baseline (Time 3).

Hierarchical multiple regression analyses of moderator effects demonstrated that patients with

higher SC perfectionism and higher levels of daily stress-sadness reactivity (i.e., greater

increases in daily sadness in response to increases in daily stress) had less improvement in

depressive symptoms at Time 3 relative to those of other patients, adjusting for the effects of

Time 1 and Time 2 depression. Furthermore, higher SC perfectionism in conjunction with an

elevated CAR predicted higher levels of depression at Time 3. In addition, lower SC

perfectionism in combination with higher levels of stress-sadness reactivity/CAR was associated

with the lowest levels of depression at Time 3. These findings highlight the importance of

targeting dysfunctional self-critical characteristics that exacerbate the impact of heightened

stress-sadness reactivity and CAR in order to generate better treatment outcomes for patients

with higher SC perfectionism.

Keywords: self-critical perfectionism, stress-sadness reactivity, cortisol, depression

Public Significance Statement: This study demonstrates that self-critical perfectionism predicts

less improvement in depression for individuals with higher stress-sadness reactivity or a higher

cortisol awakening response. The findings highlight the importance of considering perfectionism,

stress reactivity, and cortisol in the treatment of depression.

Running head: PERFECTIONISM, STRESS, AND DEPRESSION 4

Self-Critical Perfectionism and Depression Maintenance Over One Year: The Moderating

Roles of Daily Stress-Sadness Reactivity and the Cortisol Awakening Response

Depressive disorders are the second leading cause of disease burden worldwide (Ferrari

et al., 2013). Moreover, the percentage of depression recurrence ranges between 35% in the

general population to 85% in mental health care facilities (Hardeveld, Spijker, De Graaf, Nolen,

& Beekman, 2010). Thus, developing a better understanding of which characteristics relate to the

maintenance of depression will be crucial in preventing the chronicity of this serious illness.

Perfectionism is an important personality factor that has been shown to relate to the

development, maintenance, and course of depression (see Flett & Hewitt, 2002; Zuroff,

Mongrain, & Santor, 2004). Two higher-order dimensions, referred to as personal standards

(PS) and self-critical (SC) perfectionism, have consistently been identified that underlie many

different conceptualizations and measures of perfectionism (e.g., Dunkley, Zuroff, & Blankstein,

2003; see Stoeber & Otto, 2006 for a review). PS perfectionism is the setting and pursuing of

high standards and goals for oneself. Alternatively, SC perfectionism involves chronic, intense

self-scrutiny, ongoing concerns over mistakes, and severely critical views of oneself that are

associated with preoccupation regarding others’ disapproval and criticism (Dunkley, et al.,

2003). Prior findings have demonstrated that, in contrast to PS, SC perfectionism is more

strongly associated with depressive symptoms over time (Mandel, Dunkley, & Moroz, 2015). In

addition, SC perfectionism has been found to negatively contribute to the therapeutic process as

well as treatment outcomes (Blatt & Zuroff, 2005; Kannan & Levitt, 2013). Although SC

perfectionism is an important personality factor related to the maintenance of depression, little

research has highlighted under which conditions this is most likely to occur. The present study

examined daily emotional reactivity to stress and cortisol activity as potential moderating
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 5

mechanisms that contribute to the maintenance of depression over time for persons with higher

SC perfectionism in the hopes of developing better treatment strategies.

SC Perfectionism and Stress-Sadness Reactivity in Depression

According to the perfectionism diathesis-stress model, SC perfectionistic individuals are

most at risk for the development of depression when they experience high levels of stress (Flett,

Hewitt, Blankstein, & Mosher, 1995). Research has shown that SC perfectionism interacts with

stress to predict depressive symptoms over time in both nonclinical (Chang, 2000) and clinical

samples (Békés et al., 2015; Hewitt, Flett, & Ediger, 1996). Moreover, depressed patients with

higher levels of SC perfectionism were more vulnerable to future depressive symptoms

following treatment when they encountered high levels of stress (Zuroff & Blatt, 2002). Findings

based on the same sample as the current study showed that SC perfectionism interacted with

chronic stress to predict depression one year later (Békés et al., 2015).

The above studies have primarily employed between-persons designs, which test whether

perfectionism dimensions in conjunction with higher levels of stress predict individual

differences in depression. Within-person designs allow for multiple assessments of stress and

affect, which are necessary in order to better identify an individual’s typical emotional triggers.

This process mimics that which occurs in therapy, whereby the therapist and client gather

various examples of the clients’ thoughts, mood, and behaviors in response to present day events

(e.g., “I couldn’t stop thinking about the mistake I made in my work, and I felt more and more

sad as the day went on”, “I had a major disagreement with my partner, and I felt really alone”).

Therapists then create cross-sectional explanatory conceptualizations by identifying patterns

across situations that commonly trigger negative emotional reactions in the client (e.g., “when

my client appraises situations as more stressful than usual, he/she feels very sad and lonely”).
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 6

Although prior research has emphasized the presence of stress as an important moderator

of the relationship between SC perfectionism and depression, theory and research suggest that an

individual’s reaction to a stressor represents a better predictor of depression than the stressor

itself (Beck, Rush, Shaw, & Emery, 1979; Mandel et al., 2015). Beck and colleagues’ theory of

depression emphasizes that depression is partially maintained by an individual’s emotional

response to stress, such that cognitive biases interfere with the ability to regulate emotions in the

presence of stressful situations, making it difficult to overcome depressive symptomatology

(Gunthert, Cohen, Butler, & Beck, 2005). Stress reactivity as a predictor variable is not simply

the measurement of either stress or affect variables alone, it is the dynamic coupling between

stress and mood within an individual over several days. This novel method of analysis uses daily

diaries to collect a series of data points of stress and affect over time, and then multilevel

modeling is used to yield a strength-of-association variable, which reflects the degree to which

stress triggers mood in a given individual. That is, an individual slope is generated for each

participant that can then be used in separate analyses as an independent variable in order to

predict depression over time. Using this method, higher levels of stress-affect reactivity have

been shown to predict both the onset of a major depressive disorder over a period of

approximately 14 months, controlling for baseline levels of depression (Wichers et al., 2009), as

well as less improvement in depression throughout treatment (Gunthert et al., 2005). By contrast,

other research found no association between stress-affect reactivity and major depressive

disorder (MDD) over time (Wichers et al., 2010).

Stress-affect reactivity may play an important role in the relationship between SC

perfectionism and depression maintenance. Recent research has demonstrated that stress-sadness

reactivity (i.e., the dynamic coupling between daily stress and sadness) explains the relationship
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 7

between SC perfectionism and depressive and anxious symptoms over four years in a community

sample (Mandel et al., 2015). High SC perfectionists’ might experience higher levels of

depression when experiencing high levels of stress-sadness reactivity because these individuals

are likely to interpret intensified emotional reactions to stress as representing a loss of control,

which further leads to helplessness and avoidant coping tendencies that exacerbate depressive

mood (Beck et al., 1979; Dunkley et al., 2003; Flett & Hewitt, 2002). We tested the possibility

that heightened stress-sadness reactivity has a more adverse impact on the maintenance of

depression for patients with high SC perfectionism than those with low SC perfectionism.

SC Perfectionism and Cortisol in Depression

Research has also used biomarkers of psychological stress in order to further clarify the

link between stress and depression. The hypothalamus-pituitary-adrenal (HPA) axis is involved

in the physiological stress response, and one such measure of physiological stress is salivary

cortisol (Hellhammer, Wüst, & Kudielka, 2009). Cortisol is a stress hormone that plays an

important role in physical and psychological health, and is known to provide feedback to neural

structures that are involved in emotion and cognition (Rodrigues, LeDoux, & Sapolsky, 2009).

Two well-supported methods to measure cortisol activity are referred to as diurnal

cortisol secretion and the cortisol awakening response (CAR; Pruessner et al., 1997). Diurnal

cortisol secretion refers to the overall amount of cortisol release throughout the day that can be

calculated using the area under the curve with respect to ground formula (AUCg; Pruessner et

al., 2003). The relationship between diurnal cortisol release and mood has been mixed, such that

depression has been linked to both hyper- and hypoactivity of the HPA axis as demonstrated by

increased or decreased diurnal cortisol levels (Gold, Licinio, Wong, & Chrousos, 1995; Vreeburg

et al. 2013).
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 8

The CAR refers to cortisol that is produced upon awakening, and is measured by an

individual’s morning rise in cortisol. The CAR may provide an energetic “boost” that helps

individuals to prepare for upcoming daily demands (Adam et al., 2010; Chida & Steptoe, 2009;

Fries, Dettenborn, & Kirschbaum, 2009; Hoyt, Zeiders, Ehrlich, Adam, 2016). An elevated CAR

has been considered to be adaptive at times (Clow, Hucklebridge, Stalder, Evans & Thorn,

2010), and momentary increases in cortisol have been related to increases in activeness,

alertness, and relaxation (Hoyt et al., 2016). Further, recent research found that the CAR had no

relation to depression over a period of three years (Carnegie et al., 2014). On the other hand,

other findings have shown a link between the CAR and depressive symptoms, such that an

elevated CAR was found to predict major depression over a period of 2.5 years, as well as the

recurrence of major depressive episodes over time (Vrshek-Schallhorn et al., 2013).

Furthermore, a larger CAR was associated with increased likelihood of having a major

depressive episode one year later, and was shown to predict depression over and above life stress

(Adam et al., 2010). More recently, a review of the existing literature also highlighted that in

certain circumstances, a blunted CAR has been associated with depression (Dedovic & Ngiam,

2015). These mixed findings suggest that there may be individual differences that help determine

whether cortisol levels facilitate or impede improvement of depression.

Research has demonstrated a link between SC perfectionism and dysregulated cortisol

activity. Some research has found a link between higher perfectionism scores and greater area

under curve with respect to increase (AUCi) of cortisol in response to a psychosocial stress

(Wirtz et al., 2007), whereas others have found that self-critical perfectionism relates to a blunted

cortisol response to stress (Kempke, Luyten, Mayes, Van Houdenhove, & Claes, 2016). Given

that research has demonstrated that high SC perfectionism in conjunction with higher levels of
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 9

perceived stress impedes treatment of depression (Zuroff & Blatt, 2002), higher levels of cortisol

in combination with greater SC perfectionism may predict greater attenuated improvement in

depression as well. Research has yet to examine the impact of dysregulated cortisol activity on

the maintenance of depression for SC perfectionists. Higher levels of diurnal cortisol or a greater

CAR may provide an energetic boost for certain depressed patients that helps to lessen the

degree of their depressed mood (Hoyt et al., 2016). On the other hand, greater diurnal cortisol or

an amplified CAR may exacerbate SC perfectionists’ helpless response to daily demands because

of their perceived inability to sufficiently cope, leading to withdrawal and avoidant coping,

which may then contribute to depression over time (e.g., Dunkley, Mandel, & Ma, 2014).

Present Study

The present study examined daily stress-sadness reactivity and cortisol activity as

moderators of the prospective relationship between SC perfectionism and depression

maintenance over one year. Since multiple measures of cortisol exist, the current study included

two separate measures of cortisol to compare various expressions of cortisol in relation to SC

perfectionism and depression. We tested outpatients with depression over a one year period at

three time-points: (1) measures of perfectionism and depressive symptoms were collected at

Time 1; (2) daily stress-sadness reactivity, diurnal cortisol and CAR, and depressive symptoms

were measured at Time 2 six months later; and (3) depressive symptoms were again collected at

Time 3 one year following baseline. SC perfectionism was measured prior to the moderators of

interest, which is in line with the diathesis-stress model (Flett, Hewitt, Blankstein, & Mosher,

1995) that posits that certain personality charactertistics serve as enduring vulnerability factors

that place individuals at risk of experiencing negative outcomes when they encounter certain

stressors. Although the current study is based on the same sample as Békés et al. (2015), the
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 10

current study examined conceptually different questions using different methodologies. Whereas

Békés et al. (2015) tested whether perfectionism dimensions interacted with interviewer-rated

chronic stress to predict depression over time, the current study used a daily diary methodology

to assess within-person daily emotional reactivity and salivary cortisol assessments to obtain

physiological measures of stress. This helped to expand our understanding of important factors

that moderate the relationship between perfectionism and depression over time.

Our main hypotheses were that high SC perfectionism in conjuction with higher levels of

stress-sadness reactivity would predict depression maintenance over one year in persons with

depression undergoing therapy. Further, we expected that high SC perfectionism combined with

elevated levels of diurnal cortisol and/or the CAR would predict ongoing depression. Lastly,

given that there is some evidence to suggest that PS perfectionism interacts with stress to predict

negative outcomes (Békés et al., 2015), we also examined whether PS perfectionism interacts

with stress-sadness reactivity, diurnal cortisol and/or the CAR to predict depression maintenance.

Method

Participants

The present study presents additional analyses of data from the same sample of

outpatients used in Békés et al. (2015). Participants participated voluntarily after a human

investigation committee approved the study and informed consent was obtained. The current

study was comprised of a sample of 43 English- and French-speaking outpatients between the

ages of 18-65, who had a primary diagnosis of current unipolar major depression (MDD)

according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-

IV-TR; American Psychiatric Association, 2000). Participants were referred for treatment at one
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 11

of two major teaching hospitals in an eastern North American city and were eligible if they had

not had any change in medication for a minimum of four weeks prior to the study.

Participants were administered the Structured Clinical Interview for the DSM-IV, Axis I

Disorders (SCID-I; First, Spitzer, Gibbon, & Williams, 2002) to obtain a comprehensive Axis I

diagnosis. Exclusion criteria consisted of comorbid psychiatric disorders (bipolar disorder,

psychotic subtypes of depression, current substance abuse, past or present schizophrenia or

schizophreniform disorder, organic brain syndrome, and mental retardation). In addition,

participants who were undergoing concurrent psychotherapy outside of the study or who required

hospitalization because of the possibility of imminent suicide or psychosis were excluded.

Of the 65 participants who met criteria for inclusion in the study, 43 completed

perfectionism measures at Time 1, a minimum of five daily diaries at Time 2, a minimum of one

day of salivary cortisol samples at Time 2, and interviewer-rated depression measures at Time 1,

Time 2, and Time 3. The final sample of 43 participants (30 women, 13 men) completed their

Time 2 measures approximately six months later (M = 6.52, SD = .75), and their Time 3

measures approximately one year following baseline measures (M = 12.67 months, SD = 1.17).

One participant who completed Time 2 daily diaries did not complete Time 2 salivary cortisol

samples, and four participants who completed Time 2 salivary cortisol samples did not complete

a sufficient number of Time 2 daily dairies. Out of the 39 participants who completed daily

diaries, two were missing one day of daily dairies, and three were missing two nonconsecutive

days of daily dairies (e.g., days two and six). Out of the 42 participants with cortisol data, two

were missing one day of cortisol measures.

The mean age of the sample at Time 1 was 40.65 years (SD = 10.63). Participants were

primarily of European descent (70%), with 7% African, 7% West Indian, 3% East Indian, 3%
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 12

Middle Eastern, 3% Aboriginal, and 4% unspecified. Thirty-seven participants (25 female, 12

male) completed the English version of the questionnaires and six participants (5 female, 1 male)

completed the French version of the questionnaires.

Eighty-six percent of participants (n = 37) reported taking concurrent psychiatric

medication. Ninety-one percent of participants (n = 39) met concurrent SCID-I criteria for

moderate to severe depression severity, and 88% (n = 38) had a previous major depressive

episode. Sixty-five percent of participants (n = 28) met SCID-I criteria for at least one co-morbid

Axis I disorder. Fourteen percent (n = 6) met criteria for dysthymia, 23% (n = 10) met criteria for

social phobia, 21% (n = 9) met criteria for panic disorder, 21% (n = 9) met criteria for post-

traumatic stress disorder, 12% (n = 5) met criteria for generalized anxiety disorder, 12% (n = 5)

met criteria for anxiety disorder not otherwise specified, 7% (n = 3) met criteria for agoraphobia,

2% (n = 1) met criteria for obsessive-compulsive disorder, 2% (n = 1) met criteria for eating

disorder not otherwise specified, and 2% (n = 1) met criteria for a pain disorder.

Protocol

Participants were all referred for Cognitive Behavioral Therapy (CBT), but they varied in

the number of therapy sessions (M = 15.77, SD = 8.37, Mdn = 16.50, range: 1-30). Prior to their

hospital visit, at Time 1 (baseline), participants completed measures of perfectionism at home for

60-90 minutes. Following this, participants were invited for their first hospital visit, where they

completed SCID-I and the 17-item Hamilton Rating Scale for Depression (HAM-D; Hamilton,

1960) for a period of three to four hours. Licensed clinical psychologists, with doctoral degrees

that involved extensive training in diagnostic interviewing, administered both the SCID-I and the

HAM-D. In addition, the ratings from these interviews were discussed and reviewed in

consultation between the interviewers on an ongoing basis for a total of approximately 15 hours.
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 13

At Time 2 (six months later), participants were invited back to the hospital to complete the

HAM-D for the second time. Participants were also provided seven days of daily dairies to

complete and were asked to provide salivary cortisol samples on Day 1 and Day 7. At Time 3

(one year after baseline), participants were again invited back to the hospital to complete their

third and final HAM-D measure. The same interviewer conducted the HAM-D at all three

timepoints. Participants were compensated a total of $200 for completing the three assessments.

Psychological measures

English-speaking participants completed the English version of the questionnaires and

French-speaking participants completed the French version. The French versions of the Time 1

perfectionism and Time 2 stress appraisals and affect measures have been found to have similar

internal consistencies and validity as their English counterparts (Dunkley & Kyparissis, 2008;

Dunkley et al., 2014).

Perfectionism. The measures of self-critical and personal standards dimensions of

perfectionism were obtained from the following questionnaires: the 45-item Multidimensional

Perfectionism Scale (HMPS; Hewitt & Flett, 1991), the 35-item Multidimensional Perfectionism

Scale (FMPS; Frost, Marten, Lahart, & Rosenblate, 1990), the 23-item Almost Perfect Scale-

Revised (APS-R; Slaney, Rice, Mobley, Trippi, & Ashby, 2001), the 66-item Depressive

Experiences Questionnaire (DEQ; Blatt, D'Afflitti, & Quinlan, 1976), and the 40-item

Dysfunctional Attitude Scale (DAS; Weissman & Beck, 1978). Based on previous factor

analyses (e.g., Dunkley et al., 2003; Dunkley et al., 2017; see Stoeber & Otto, 2006 for a

review), SC perfectionism was assessed by the following subscales in their entirety: DEQ self-

criticism, DAS self-criticism, FMPS concern over mistakes, HMPS socially prescribed

perfectionism and APS-R Discrepancy. PS perfectionism was measured by the full version of
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 14

each of the following subscales: HMPS self-oriented perfectionism, FMPS personal standards,

and APS-R high standards. A growing number of studies have represented SC and PS

perfectionism through composite scores created by combining two or more subscales from

several key perfectionism models because this offers an empirically-based integration of multiple

lines of theoretical and empirical work (e.g., Békés et al., 2015; Dunkley et al., 2003; Mandel et

al., 2015). In keeping with previous studies (e.g., Békés et al., 2015; Mandel et al., 2015), the

selected FMPS, HMPS, APS-R, DEQ, and DAS perfectionism measures were standardized into

z-scores and then averaged together to create the SC composite score (FMPS concern over

mistakes + HMPS socially prescribed perfectionism + APS-R discrepancy + DEQ self-criticism

+ DAS perfectionism) and PS composite score (FMPS personal standards + HMPS self-oriented

perfectionism + APS-R high standards).

The internal consistencies of SC and PS composites were previously reported as .77 and

.90 (Dunkley et al., 2014), and in the present study were .80 and .75, respectively. Support has

been found for the convergent and discriminant validity of the SC and PS composite scores. For

example, PS composites have been associated with conscientiousness, in contrast to SC

composites that have been associated with neuroticism, daily stress, maladaptive coping, and

depressive symptoms (e.g., Dunkley et al., 2017; Dunkley et al., 2014; Dunkley et al., 2003).

Interviewer-Rated Depressive Symptoms. Depression severity was measured using the

17-item Hamilton Depression Rating Scale (HAM-D; Hamilton, 1960), which is the most widely

used interviewer-rated measure of depression. The HAM-D has shown good internal

consistency, with a mean alpha coefficient of .79 across various studies, and has demonstrated

higher variability of scores and greater internal consistency at lower mean depression scores

compared to higher mean scores (Trajković et al., 2011). As seen in Table 1, the present study
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 15

demonstrated a similar pattern, such that internal consistency for the HAM-D increased from .59

to .93 from Time 1 to Time 2 and then to .85 at Time 3, respectively, as depression scores

decreased on average from Time 1 to Time 2 and Time 3. The HAM-D has demonstrated good

inter-rater reliability, with a pooled mean ICC of .93 for independent interviews (Trajković et al.,

2011). Although there was no formal check on inter-rater reliability for the HAM-D, as

previously mentioned the two highly trained interviewers met regularly to consult and calibrate

on various interviews. The HAM-D is sensitive to changes in depression severity and is

moderately related to other measures of depression (Katz, Shaw, Vallis, & Kaiser, 1995). For

French participants, the interview guide questions were translated into French by the bilingual

interviewer. To ensure that the original meaning of each probe was preserved, the guide

questions were translated using thorough forward and backward translation techniques.

Daily Diary Measures

Participants were provided seven stamped envelopes, each containing a daily diary

questionnaire. Participants were instructed to complete one diary at bedtime for seven

consecutive nights. The diary included questionnaires measuring daily affect and stress

appraisals. Participants were asked to mail the envelope with the completed diary the following

morning. Participants were encouraged to complete the diaries every evening. If this was not

possible, participants were asked to complete them as soon as possible the following morning.

Participants were contacted on days three and five to remind them to complete the daily diaries.

Daily Affect. Present day levels of sadness were measured using the Positive and

Negative Affect Schedule-Expanded (Watson & Clark, 1994) 5-item scale. Good within- and

between-persons reliability and validity has been established in evaluating this form of daily

affect (Dunkley et al., 2014; Mandel et al., 2015), and the within- and between- person
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 16

reliabilities, calculated using Cranford and colleagues’ (2006) procedure, in the present study

were .84 and .94, respectively.

Event Appraisals. Consistent with previous studies (e.g., Dunkley et al., 2014; Dunkley

et al., 2003), participants were asked to describe their most bothersome event of today and rate

the event on a number of aspects: “how unpleasant was the event or issue to you?” (1 = not at all

to 11 = exceptionally), “for how long were you bothered by the event or issue?” (1 = a very brief

amount of time to 7 = a very large amount of time), and “how stressful was the event or issue for

you?” (1 = not at all to 11 = exceptionally). In order to calculate event stress, the length of the

appraisal item score was rescaled to be on an 11-point scale as opposed to a 7-point scale, and

the average of the three appraisal items (i.e. unpleasantness, length, and stressfulness) was

calculated in order to establish an event stress score that reflected both the degree and duration of

difficulty of the participant’s most bothersome event of the day. The most bothersome daily

event measure has been found to be internally consistent as well as valid (Dunkley et al., 2014;

Dunkley et al., 2003). Using Cranford and colleagues’ (2006) procedure, the within- and

between-persons reliabilities for event stress were .82 and .75, respectively.

Stress-sadness reactivity. In order to create variables to assess daily stress-sadness

reactivity, we conducted multilevel modeling using SAS PROC MIXED (Version 9.2) and

maximum likelihood estimation. Specifically, within-person daily variability in sadness was

predicted from within-person fluctuations in event stress (with the slope modeled as randomly

varying across participants). The individual slopes were empirical Bayes estimates, and the

variance associated with these slopes was significant. The resulting regression coefficient

represents the individual-level component of the slope for each participant, which was then used

as a between-persons stress-sadness reactivity variable in the hierarchical multiple regression

Running head: PERFECTIONISM, STRESS, AND DEPRESSION 17

analyses. The calculation of individual stress-sadness reactivity slopes to be utilized in between-

person analyses has been supported in previous research (Mandel et al., 2015). Figure 1 depicts

the within-person covariation between stress and sadness for a participant with a higher stress-

sadness reactivity slope compared to a participant with a lower reactivity slope, with the

measures of stress and sadness standardized for each participant for illustration purposes.

Cortisol Measures

Participants were provided with a saliva kit to take home and were asked to provide a

sample of their saliva at five specific times during each target day. Participants were given

detailed instructions, both written and verbal, for the salivary cortisol collection. They were

asked not to brush their teeth prior to providing the sample and to avoid food intake prior to

testing. We utilized the Medication Event Monitoring System (MEMS®), a well-validated

electronic monitoring system that allows researchers to analyze and monitor participant’s

compliance with the prescribed time of saliva sampling in the natural environment. The system is

comprised of two parts: a standard plastic vial with threaded opening and a closure for the vial

that contains a micro-electronic circuit that registers times when the closure is opened and when

it is closed. The results obtained with the MEMS® are widely regarded as the gold standard

measure of patient compliance (Kudielka, Broderick, & Kirschbaum, 2003). After collecting

their saliva samples, participants were asked to store them in their home freezers prior to

dropping them off to a member of the research team prior to their next CBT session. Assaying

salivary cortisol was performed in the laboratory of Dr. N.M.K. Ng Ying Kin at the Douglas

Hospital Research Centre. The ICN radioimmunoassay kit for plasma cortisol was obtained from

Medicorp (Montreal) and modified for the determination of salivary cortisol.

Running head: PERFECTIONISM, STRESS, AND DEPRESSION 18

On Days 1 and 7 of the diary collection, participants provided saliva samples at

awakening, 30 minutes after awakening (M = 34.20, SD = 11.40 minutes), 14h00 (M = 5.76, SD

= 1.85 hours after last morning sample), 16h00 (M = 2.54, SD = 1.49 hours after 14h00 sample),

and before bedtime (M = 7.01, SD = 1.85 hours after 16h00 sample), and there was an average of

15.41 hours (SD = 2.63) between their first and fifth saliva sample. These time points have been

used in previous research to measure diurnal HPA-axis functioning (Juster et al., 2016). Diurnal

cortisol levels were measured using the area under the curve with respect to ground (AUCg)

formula, as recommended by Pruessner et al. (2003). Morning cortisol increase was measured by

calculating the CAR, which allows for a more stable, noninvasive measurement of HPA activity

that does not rely on stressor tasks that may vary between studies (Carnegie et al., 2014; Chida &

Steptoe, 2009). Participants’ saliva at the time of awakening and 30 minutes after awakening was

used to calculate the CAR value, with daily cortisol levels at 30 minutes post awakening

subtracted from cortisol levels at awakening. The average of the two diurnal cortisol and CAR

levels from Days 1 and 7 were used in order to represent each participant’s diurnal cortisol and

CAR levels, respectively (Therrien et al., 2008). In line with previous research (Juster et al.,

2016), we computed MEMS compliance for the CAR value by calculating the sum of the

absolute difference in minutes for both our cortisol measurement days between a participant’s

actual recording and the recommended sampling time of +30 minutes following wakening.

Participants were generally compliant with the +30 minutes after awakening time-point, showing

only limited deviations (M = 14.36 minutes, SE = 2.86). The value calculated for the MEMS

compliance for the CAR was also not correlated with any other variables in the study.

Compliance for the diurnal cortisol levels was not computed as participants were given more

flexibility with varying awakening and bedtime time-points.

Running head: PERFECTIONISM, STRESS, AND DEPRESSION 19

Results

Descriptive Statistics

The means and standard deviations for the Time 1 SC and PS perfectionism, Time 2 daily

stress-sadness reactivity, diurnal cortisol, and CAR, and Time 1, 2 and 3 depression measures are

presented in Table 1. Nested analysis of variance (N-ANOVA) results suggested 74.1% within-

person and 25.9% between-persons variation in Time 2 daily stress and 29.8% within-person and

70.2% between-persons variation in Time 2 sadness. As reported in Békés et al. (2015),

depression scores demonstrated a significant decrease between Time 1 and Time 2, Time 1 and

Time 3, and Time 2 and Time 3. Results from t-tests comparing the means for the Time 1

depression and personality measures showed no significant differences between the 22

participants who did not complete all three time points and the 43 who did complete all three

time points. Moreover, results from t-tests showed no significant differences for Time 1, Time 2,

and Time 3 depression, Time 1 personality measures, Time 2 stress-sadness reactivity and either

of the Time 2 cortisol measures between men versus women, participants with versus without a

history of major depression, participants with versus without a co-morbid Axis I disorder, and

participants who were versus were not taking psychiatric medication at the beginning of the

study. Number of therapy sessions was not significantly correlated with Time 3 depression.

Correlations

The relations between Time 1 SC and PS perfectionism, Time 1, Time 2, and Time 3

HAM-D for the present sample were previously reported by Békés et al. (2015). Correlations

shown in Table 1 indicate that Time 1 SC perfectionism was significantly correlated with Time 3

depression scores only, whereas Time 1 PS perfectionism did not correlate significantly with any

of the stress-sadness reactivity, cortisol, or depression variables in the analyses. Time 2 daily
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 20

stress-sadness reactivity was moderately to strongly related to Time 1, Time 2, and Time 3

depression scores, as well as Time 2 CAR. Time 2 diurnal cortisol and CAR were strongly

related, but neither cortisol variable was significantly related to Time 2 or Time 3 depression.

Hierarchical Multiple Regression Analyses

Three separate hierarchical multiple regression analyses were performed in order to

examine whether Time 2 (1) daily stress-sadness reactivity, (2) diurnal cortisol, and (3) CAR

moderate the relationship between Time 1 SC perfectionism and Time 3 depression scores. All

predictor variables were standardized. Time 1 SC perfectionism was combined into interaction

terms with each Time 2 variable (stress-sadness reactivity, diurnal cortisol, CAR) predicting T3

HAM-D, which represented the three separate hierarchical multiple regressions. Each variable

was entered into the hierarchical multiple regression one step at time, which is the method used

by Hewitt, Flett, and colleagues to examine moderator hypotheses (Hewitt et al., 1996) and

incorporates an incremental partitioning of variance (Cohen, Cohen, West, & Aiken, 2003).

In order to control for depression, Time 1 and Time 2 depression scores were entered in

the first and second block of the hierarchical multiple regression. In order to control for the main

effect of the predictors prior to testing the relevant interaction, the Time 2 stress-sadness

reactivity/diurnal cortisol/CAR variable was entered in the third block and the Time 1 SC

perfectionism score was entered in the fourth block. The fifth and final block of the regression

included the relevant interaction term between Time 1 SC perfectionism and each of the Time 2

stress-sadness reactivity, diurnal cortisol, and CAR variables separately. Collinearity diagnostics

across the regression analyses suggested that there was no cause for concern about

multicollinearity, as variance inflation factors (all ≤ 2.56) were well below the typically used

cutoff of 10 and tolerance values (all ≥ .39) were well above typically used cutoff of .10 (see
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 21

Cohen et al., 2003). In addition, there were no significant outliers as residuals (all < |2.43|) were

well below the typical threshold of 3 standard deviations. As shown in Table 2, Time 1 HAM-D

scores predicted a nonsignificant amount of unique variance in Time 3 HAM-D scores, whereas

Time 2 HAM-D scores accounted for a significant amount of additional variance in Time 3

HAM-D scores (p < .01) over and above Time 1 HAM-D depression scores. Results for the SC

perfectionism, stress-sadness reactivity, and cortisol variables are described below.

SC perfectionism and daily stress-sadness reactivity predicting depression. As

displayed in Table 2, Time 2 stress-sadness reactivity accounted for a nonsignificant amount of

unique variance in Time 3 HAM-D depression scores. Time 1 SC perfectionism predicted a

significant 11% of additional variance (p < .05) in Time 3 depression scores, above and beyond

Time 1 and Time 2 HAM-D depression scores. Lastly, Time 1 SC perfectionism interacted with

Time 2 stress-sadness reactivity to predict a significant 12% of unique variance (p < .01) in Time

3 HAM-D depression scores. Effect sizes were calculated using Cohen’s f2 test, which

demonstrated that the interaction between Time 1 SC perfectionism and Time 2 stress-sadness

reactivity predicting Time 3 HAM-D had a moderate effect size of .14 (Cohen, 1988). When

entering PS as opposed to SC in the fourth block, PS perfectionism predicted a significant 8% of

unique variance (β = .27, p < .05) in Time 3 HAM-D scores. However, the interaction between

PS and Time 2 stress-sadness reactivity was entered into the fifth block and predicted a

nonsignificant amount of incremental variance (ΔR2 = .003, p = .67).

In keeping with recommendations by Cohen et al. (2003), the significant interaction was

interpreted by calculating the simple slope at each level of the independent variables, which was

represented as one standard deviation above or below the mean. As demonstrated in Figure 2, for

patients with high levels of Time 2 stress-sadness reactivity, there was a significant positive
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 22

relation between Time 1 SC perfectionism and Time 3 depression scores, slope = 6.59, SE =

1.57, t(33) = 4.20, p < .01. In contrast, the relationship between Time 1 SC perfectionism and

Time 3 depression scores was nonsignificant for patients with low levels of Time 2 stress-

sadness reactivity. In addition, comparison of point estimates demonstrate that low levels of

Time 1 SC perfectionism in conjunction with high levels of Time 2 stress reactivity is

significantly lower than the mean of the three other points in Figure 2, t(33) = 3.11, p < 0.01.

SC perfectionism, diurnal cortisol, and CAR predicting depression. Time 2 diurnal

cortisol predicted a nonsignificant amount of incremental variance (ΔR2 = .01, p = .54) in Time 3

HAM-D depression scores. Time 1 SC perfectionism accounted for a significant 8% of

additional variance (p < .05) in Time 3 depression scores, above and beyond Time 1 and Time 2

HAM-D scores. However, Time 1 SC perfectionism did not interact with Time 2 diurnal cortisol

to predict changes in Time 3 HAM-D depression scores (ΔR2 = .000, p = .95).

As shown in Table 2, Time 2 CAR predicted a nonsignificant amount of incremental

variance in Time 3 HAM-D depression scores. Time 1 SC perfectionism accounted for a

significant 8% of additional variance (p < .05) in Time 3 depression scores, above and beyond

Time 1 and Time 2 HAM-D scores. Lastly, Time 1 SC perfectionism interacted with Time 2

CAR to predict a significant 14% of unique variance (p < .01) in Time 3 depression. Results of

Cohen’s f2 test suggested that the interaction between Time 1 SC perfectionism and Time 2 CAR

predicting Time 3 depression had a moderate effect size of .17 (Cohen, 1988). When PS replaced

SC in the fourth block, PS perfectionism was found to predict a significant 8% of unique

variance (β = .35, p < .05) in Time 3 depression scores. Following this, however, when PS X

Time 2 CAR was entered into the fifth block, the effect was nonsignificant (ΔR2 = .02, p = .23).
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 23

As shown in Figure 2, for patients with high levels of Time 2 CAR, there was a

significant positive relation between Time 1 SC perfectionism and Time 3 depression scores,

slope = 6.14, SE = 1.39, t(36) = 4.41, p < .01. For patients with low levels of Time 2 CAR, the

relationship between Time 1 SC perfectionism and Time 3 depression was nonsignificant.

Furthermore, comparison of point estimates demonstrate that low levels of Time 1 SC

perfectionism in conjunction with high levels of Time 2 CAR is significantly lower than the

mean of the three other points in Figure 2, t(36) = 4.15, p < 0.01.

Discussion

The present study demonstrated that daily stress-sadness reactivity and cortisol activity

moderate the relationship between SC perfectionism and depression over time. Our first set of

findings demonstrated that patients with higher SC perfectionism and higher levels of daily

stress-sadness reactivity had higher levels of depression at Time 3 relative to those of other

patients, adjusting for the effects of Time 1 and Time 2 depression. Furthermore, SC

perfectionism in combination with lower levels of stress-sadness reactivity was not associated

with higher levels of depression at Time 3. In addition, our findings show that lower SC

perfectionism in conjunction with high stress-sadness reactivity predicted the lowest levels of

depression one year later.

These findings extend the perfectionism diathesis-stress model by highlighting the

importance of stress-sadness reactivity as particularly maladaptive in the relationship between

SC perfectionism and depression. These results also provide further support for Beck et al.’s

(1979) theory of depression, by emphasizing the importance of how one reacts to a stressor.

Furthermore, these findings are in line with theory that suggests that certain people with

vulnerability to depression have greater difficulty disengaging from negative emotions (i.e.
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 24

sadness) in the face of stressors, likely because these stressors prime their dysfunctional

attitudes, which lead to depressive episodes over time (Williams, Teasdale, Segal, & Kabat-Zinn,

2007). Similar results were not found for PS perfectionism, which is consistent with previous

research highlighting that SC perfectionism represents the more maladaptive dimension of

perfectionism (Mandel et al., 2015; Dunkley et al., 2003). Our findings are also in line with

previous research demonstrating a link between SC perfectionism and depression maintenance

(Zuroff & Blatt, 2002), but further add to the literature by better identifying under which

conditions this relationship occurs.

A possible explanation for why high SC perfectionists’ experience higher levels of

depression when experiencing high levels of stress-sadness reactivity is that high SC

perfectionists tend to interpret stressors as representing a failure of the self and a potential loss of

control, which perpetuates helplessness thinking and avoidant coping tendencies that further

prolong dysphoric emotions (Beck et al., 1979; Dunkley et al., 2003; Flett & Hewitt, 2002).

Further, the presence of sadness has also been linked to more avoidance and withdrawal

behaviors (see Carver & Harmon-Jones, 2009). Thus, high stress-sadness reactivity may place

high SC perfectionists at an especially high risk of maintaining depressive symptoms over time.

Interestingly, our findings also demonstrate that high stress-sadness reactivity is

protective for those with lower levels of SC perfectionism. Lower SC perfectionistic individuals,

in contrast to higher, may be more skilled at distancing themselves from their appraisal-emotion

responses, allowing them to better accept and cope with their difficulties in an open,

compassionate manner, as opposed to avoiding them, which may contribute to fewer depressive

symptoms over time (Gilbert & Procter, 2006; Hayes, Strosahl, & Wilson, 2012; Niles et al.,

2013). In addition, emotional reactions serve to communicate information and to elicit

Running head: PERFECTIONISM, STRESS, AND DEPRESSION 25

potentially helpful responses from others (Rottenberg & Vaughan, 2008). It is possible that

individuals with low SC perfectionism who have high levels of stress-sadness reactivity show the

most improvement in depression because their expression of sadness in the face of stressors

helps them to communicate their needs and elicits more social support from others.

Our second set of findings demonstrated that higher SC perfectionism, in conjunction

with a heightened CAR, predicted the highest level of depression maintenance over a one-year

period, adjusting for the effects of Time 1 and Time 2 depression. Our results also demonstrate

that low SC perfectionism in combination with a high CAR predicts the lowest levels of

depression. Our findings help to reconcile the previously mixed findings between the CAR and

depression (Adam et al., 2010; Carnegie et al., 2014; Vrshek-Schallhorn, 2013) by demonstrating

the heterogeneous nature of the effect of CAR. In contrast, however, diurnal cortisol activity did

not interact with SC perfectionism to predict depression. This suggests that an elevated rise in

cortisol in the morning, as opposed to overall stress hormone levels throughout the day, interacts

with SC perfectionism to predict depression. This discrepancy between results found for diurnal

cortisol levels in comparison to the CAR is in line with previous research (Adam et al., 2010;

Vreeburg et al., 2013). An elevated CAR may be more detrimental than high diurnal cortisol

levels because CAR appears to be impacted by both genetic and environmental influences, which

together may result in particularly maladaptive outcomes for those at risk for depression (Chida

& Steptoe, 2009). Further, given that research has suggested a possible link between the CAR

and preparing for upcoming daily demands (Adam et al., 2010; Chida & Steptoe, 2009; Fries,

Dettenborn, & Kirschbaum, 2009), a high CAR in high SC perfectionists may represent potential

distress because they anticipate that they are unable to adequately cope with the upcoming
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 26

demands, leading them to respond with a helplessness orientation and avoidance, which may

lead to increases in depression over time (e.g., Dunkley et al., 2003; Dunkley et al., 2014).

On the other hand, an elevated CAR in low SC perfectionists’ may signal an adaptive

response as low SC perfectionists’ are able to better cope in the face of perceived daily demands

and stressors (Fries, Dettenborn, & Kirschbaum, 2009). Moreover, an elevated CAR may

provide an energetic boost that includes increases in activeness, alertness, and relaxation (Hoyt et

al., 2016), which may provide low SC perfectionists with the added energy that they need to

challenge their depressive thoughts or engage in more behavioral activation. In short, the

presence of an elevated CAR may be adaptive in certain circumstances (Clow et al., 2010),

however, the increase in stress hormone in high SC perfectionists may signal a more helpless

rather than opportunitistic response.

Clinical Implications

In understanding the precise nature of the implications of findings linking perfectionism

to negative therapeutic outcome (Blatt & Zuroff, 2005), these findings underscore the importance

of focusing on self-critical evaluative tendencies rather than high personal standards and active

striving to attain perfection (e.g., Dunkley et al., 2003; see Stoeber & Otto, 2006). In order to

provide more effective treatment for high SC perfectionistic patients, future interventions should

target dysfunctional self-critical characteristics (e.g., maladaptive coping, contingent self-worth

beliefs) that exacerbate the impact of heightened stress-sadness reactivity and an elevated CAR

in order to generate better treatment outcomes (Dunkley et al., 2003). By targeting dysfunctional

self-critical characteristics, treatment may help high SC perfectionists to more constructively

interpret heightened levels of stress and physiological changes as adaptive and helpful. SC

perfectionistic attitudes can be further targeted by working to increase levels of self-compassion,

Running head: PERFECTIONISM, STRESS, AND DEPRESSION 27

which may involve learning to genuinely care for oneself, become sensitive, non-judgmental and

tolerant of distress, and respond with self-warmth and caring in the face of difficulty. This form

of treatment, also referred to as compassionate mind training (CMT), has been shown to be

effective for self-critical individuals (Gilbert & Procter, 2006). In addition, cognitive

restructuring that helps to minimize overemphasis on the negative impact of daily stressors may

help to reduce these exaggerated emotional/physiological stress responses for high SC

perfectionists (Niles, Mesri, Burklund, Lieberman, & Craske, 2013). Lastly, interventions that

contain acceptance and mindfulness techniques, which provide strategies for distancing from,

observing and accepting ones’ emotions, may help high SC perfectionistic patients to react less

negatively when faced with stress (Hayes et al., 2012; Niles et al., 2013).

Limitations and Future Directions

Though the current study advances previous literature on the topic, it also contains some

important limitations. First, our results are based on a relatively small sample that was

predominately of European descent; therefore, future research should aim to include a larger,

ethnically diverse sample in order to assess the generalizability of our findings. Second, future

research should examine models that include additional explanatory mechanisms that aim to

explain why high SC perfectionists, in sharp contrast to low SC perfectionists, exhibit a

maladaptive response to stress-sadness reactivity and a heightened CAR. Possible additional

mechanisms that may be of interest include maladaptive coping, such as avoidance (Dunkley et

al., 2014), versus adaptive coping styles that focus on more mindful, self-compassion oriented

coping (Gilbert & Procter, 2006; Hayes, Strosahl, & Wilson, 2012). Third, we recommend

additional daily CAR measurements in future studies to better distinguish between trait versus

state stress mechanisms, as well as more cortisol collections throughout the day (e.g., at 45
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 28

minutes, 60 minutes post waking) to examine variability in average CAR peak times. Lastly,

future research should examine whether our findings generalize to other clinical and nonclinical

populations.

Conclusion

The present study used individual stress-sadness reactivity slopes and the cortisol

awakening response to better comprehend the relationship between SC perfectionism and

depression one year later in patients with depression. Results demonstrated that higher SC

perfectionism predicted less improvement in depressive symptoms over a period of one year for

individuals with high levels of stress-sadness reactivity or a higher CAR. Furthermore, findings

also showed that, for lower SC perfectionists, higher stress-sadness reactivity or CAR serve as

protective mechanisms against depressive symptoms.

Running head: PERFECTIONISM, STRESS, AND DEPRESSION 29

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Running head: PERFECTIONISM, STRESS, AND DEPRESSION 37

Table 1
Correlations, Means, and Standard Deviations of the Perfectionism, Stress-Sadness Reactivity, Diurnal Cortisol (AUCg), Cortisol Awakening
Response (CAR), and Depression Measures

Variables 1 2 3 4 5 6 7 8

1. T1 SC Perfectionism --
2. T1 PS Perfectionism .65*** --
3. T1 HAM-D .27 .12 --
4. T2 Stress-Sad React .21 -.04 .36* --
5. T2 AUCg -.02 -.06 .15 .27 --
6. T2 CAR .04 .18 .32* .34* .56*** --
7. T2 HAM-D .11 -.03 .51** .70*** .30 .23 --
8. T3 HAM-D .34* .25 .29 .48** .10 .06 .59*** --
M .00 .00 21.19 .00 4.58 .16 15.42 13.12
SD .83 .92 5.12 .05 4.27 .32 8.19 7.86
Note. T1 = Time 1. T2 = Time 2. T3 = Time 3. SC = Self-Critical. PS = Personal Standards. HAM-D = Hamilton Rating Scale for Depression.
Stress-Sad React = Stress-Sadness Reactivity. AUCg = Area under the curve with respect to ground. CAR = Cortisol Awakening Response.
* p < .05; ** p < .01; *** p < .001.
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 38

Table 2
Hierarchical Multiple Regression Analyses Predicting Time 3 Depressive Severity with
Stress-Sadness Reactivity (top), Cortisol Awakening Response (CAR) (middle) and Area
under the curve with respect to ground (AUCg) (bottom) and Perfectionism

Adj.
Variables B SE B 95% CI β ΔR2 df ΔF
R2

SC Perfectionism X Stress-sadness reactivity predicting T3 HAM-D

T1 HAM-D .05 .22 [-.40, .50] .04 .05 .07 1, 37 2.84

T2 HAM-D .49 .16 [.16, .81] .53 .28 .25 1, 36 13.26**
T2 Stress-sadness
-1.35 1.41 [-4.21, 1.51] -.18 .28 .01 1, 35 .74
reactivity
T1 SC Perfectionism 3.15 .93 [1.26, 5.05] .43 .38 .11 1, 34 6.90*
T1 SC X T2 SR 3.44 1.12 [1.15, 5.73] .44 .50 .12 1, 33 9.36**

SC Perfectionism X CAR predicting T3 HAM-D

T1 HAM-D -.09 .20 [-.50, .33] -.06 .06 .08 1, 40 3.56

T2 HAM-D .52 .12 [.27, .76] .54 .32 .27 1, 39 16.13***
T2 CAR -.69 .89 [-2.50, 1.12] -.09 .31 .01 1, 38 .45
T1 SC Perfectionism 2.80 .89 [1.00, 4.60] .36 .38 .08 1, 37 5.52*
T1 SC X T2 CAR 3.34 .95 [1.41, 5.28] .39 .53 .14 1, 36 12.30**

SC Perfectionism X AUCg predicting T3 HAM-D

T1 HAM-D -.17 .24 [-.65, .32] -.11 .06 .08 1, 40 3.56

T2 HAM-D .60 .14 [.31, .90] .63 .32 .27 1, 39 16.13***
T2 AUCg -.49 1.12 [-2.27, 1.77] -.06 .31 .01 1, 38 .38
T1 SC Perfectionism 2.33 1.02 [.26, 4.40] .30 .38 .08 1, 37 5.38*
T1 SC X T2 AUCg -.15 2.16 [-4.53, 4.24] -.01 .36 .00 1, 36 .01

Note. T1 = Time 1. T2 = Time 2. T3 = Time 3.

SC = Self-critical. PS = Personal standards. HAM-D = Hamilton Rating Scale for
Depression. SR = Stress-Sadness Reactivity. CAR = Cortisol Awakening Response.
AUCg = Area under the curve with respect to ground.
* p < .05. ** p < .01. *** p < .001.
Running head: PERFECTIONISM, STRESS, AND DEPRESSION 39

Figure 1: Within-person covariation between stress and sadness for a participant with a higher
stress-sadness reactivity slope compared to a participant with a lower reactivity slope.

High Stress-Sadness
Reactivity
2

0
1 2 3 4 5 6 7
-1

-2

stress sadness

Low Stress-Sadness
Reactivity
3
2
1
0
1 2 3 4 5 6 7
-1
-2

stress sadness
 Running head: PERFECTIONISM, STRESS, AND DEPRESSION 40

Figure 2. The moderating role of Time 2 (T2) stress-sadness reactivity (SR; top) and cortisol
awakening response (CAR; bottom) on the relationship between Time 1 (T1) self-critical (SC)
perfectionism and Time 3 (T3) depressive severity. Values for SC perfectionism, SR, and CAR
are plotted using low (one standard deviation below the mean) and high (one standard deviation
above the mean) values.

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