Corry et al. Int J Bipolar Disord (2017) 5:34 DOI 10.1186/s40345-017-0102-8 RESEARCH Open Access Does perfectionism in bipolar disorder pedigrees mediate associations between anxiety/stress and mood symptoms? Justine Corry1,2, Melissa Green1,2,4, Gloria Roberts1,2, Janice M. Fullerton4,5, Peter R. Schofeld4,5 and Philip B. Mitchell1,2,3* Abstract 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 anxi- ety, 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 asso- ciations between anxiety/stress and BD symptoms. Results: Self-oriented perfectionism was associated with chronic depressive symptoms; socially-prescribed perfec- tionism 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 perfection- ism in attempt to reduce depression and (hypo)manic symptoms in addition to appropriate pharmacotherapy. Keywords: Bipolar disorder, Anxiety, Stress, Psychology Background between anxiety disorders and BD are not fully under- Te high rate of comorbidity between anxiety disorders stood (Mitchell 2015; Provencher et al. 2012). To move and bipolar disorder is well established (Pavlova et al. beyond purely descriptive studies, we propose that these 2015). Anxiety disorders have been shown to precede disorders co-occur because they share common main- the onset of bipolar disorder (BD) (de Graaf et al. 2003; taining processes (Harvey et al. 2004). Cognitive styles Perugi et al. 2001) and there are high rates of anxiety are important maintaining factors in cognitive models disorders in families afected by BD (Nurnberger et al. of psychopathology (Harvey et al. 2004), and we pro- 2011; Perich et al. 2015; Merikangas et al. 2014). How- pose that the cognitive style of perfectionism may be an ever, the mechanisms that underlie the comorbidity explanatory factor in the high co-occurrence of BD and AD’s. Here, we specifcally examined perfectionism as a potential mediator of known associations between anxi- *Correspondence: [email protected] ety and stress symptoms and mood symptomatology 1 School of Psychiatry, University of New South Wales, Randwick, NSW 2031, Australia (Alloy et al. 2006; Boylan et al. 2004; Corry et al. 2013), in Full list of author information is available at the end of the article a large family study. © The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Corry et al. Int J Bipolar Disord (2017) 5:34 Page 2 of 11 Te development of BD is infuenced strongly by genet- controls and were correlated with number of hospitali- ics, accounting for as much as 85% of the variance in who zations for mania and BD episodes in general (Lam et al. develops mania (McGufn et al. 2003). In families, a sum- 2004). Hewitt et al. (1998) examined perfectionism as a mary of 5 studies estimated that the risk of an afective multidimensional construct in a mixed sample of unipo- disorder in frst degree relatives of those with BD ranges lar and BD patients. Hewitt found that self-oriented per- from 24 to 31% and the risk of BD ranges from 7 to 22% fectionism (whereby the individual has high standards (Merikangas et al. 2002). Given this high genetic contri- for themselves) was uniquely associated with chronic bution to the development of BD, there remains the task depression symptoms, while socially-prescribed perfec- of identifying how and when this biological vulnerability tionism (whereby individuals perceive that others have is expressed with more proximal biological, psychologi- high standards for them) was been uniquely associated cal and environmental triggers being important factors with chronic (hypo)manic symptoms (Hewitt et al. 1998). (Johnson 2005; Jones and Bentall 2008) BD pedigrees A perfectionistic cognitive style has also been associated have higher rates of Schizoafective Disorder (BD type), with anxiety and stress symptoms (Hewitt and Flett 2002; BD-I, BD-II and Major Depressive Disorder that control Frost and DiBartolo 2002; Wheeler et al. 2011). Previ- families (Gershon et al. 1982). Tere is also emerging ous associations with perfectionism extend to variations evidence that the family environment plays an impor- in state and trait anxiety (Flett et al. 1995), social anxiety tant role in infuencing the development of beliefs and disorder (Juster et al. 1996), obsessive–compulsive dis- attitudes related to achievement and attainment of goals order (Antony et al. 1998), panic disorder (Antony et al. (Johnson 2005; Chen and Johnson 2012). Hence, studies 1998) and a tendency to worry (Chang 2000). Consistent of extended families with some members diagnosed with with this, greater levels of perfectionism have also been BD may be useful to determine the contribution of per- associated with greater cortisol responses to stress in sit- fectionistic cognitions and beliefs relating to goal attain- uations designed to induce a fear of negative evaluation ment to anxiety, stress, and other core mood symptoms (Wirtz et al. 2007) a core cognitive style in social anxiety such as depression and hypomania. disorder. Tese fndings, which confrm perfectionism as Cognitive models of the development of psychopa- a key cognitive style in both BD and the anxiety disor- thology propose that cognitive, mood and behavioural ders, provided the impetus to examine perfectionism as a symptoms arise when maladaptive beliefs and cogni- potential mediator of known associations between anxi- tions are triggered by congruent life events (Beck et al. ety and stress symptoms and mood symptomatology. 1979). Recently, cognitive models of BD symptoms and Consistent with the psychological models of BD symp- mood dysregulation have been proposed that attempt to toms (Holmes et al. 2008; Mansell et al. 2007), we have explain both the depressive and (hypo)manic symptoms previously reported that anxiety and stress symptoms characteristic of BD (Holmes et al. 2008; Mansell et al. mediated the efects of self-critical perfectionism and 2007). Mansell et al. (2007) have proposed a transdiag- goal attainment beliefs on current bipolar depressive nostic model of mood dysregulation and bipolar disorder, symptoms after controlling for current hypomanic symp- within which it is proposed that self-critical or shaming toms (Corry et al. 2013). For hypomanic symptoms, stress beliefs may be important in driving anxious thoughts and symptoms were a signifcant mediator of the relationship cognitive appraisals of afect, as well as bodily sensations between self-critical perfectionism and current hypo- that ultimately infuence the ascent into (hypo)mania or manic symptoms; however, these mediation models were descent into depression (Mansell et al. 2007). In paral- no longer signifcant after controlling current depressive lel, a separate cognitive model of BD emphasizes the role symptoms. Similar fndings were reported by O’Garro- that anxiety plays in the development of BD symptoms Moore et al. (2015) using prospective data from those (Holmes et al. 2008). Te model of Mansell et al. (2007) with bipolar spectrum disorders. Of the six cognitive in particular draws on fndings that perfectionism is a styles examined as mediators, only perfectionism was a core cognitive style of BD, along with high self-criticism signifcant mediator of the relationship between the pres- and an emphasis on goal attainment and avoidance of ence of an anxiety disorder and depressive symptoms. No failure (Alloy et al. 2009a; Lam et al. 2004; Mansell and cognitive styles signifcantly mediated the relationship Pedley 2008; Scott et al. 2000). For example, in a prospec- between anxiety disorder and hypomanic symptoms. tive study, self-criticism, performance focus and high Tis study thus examined the hypotheses that per- self-standards interacted with congruent life events to fectionism and goal attainment values would mediate predict both depressive and (hypo)manic symptoms in the associations between (subclinical) anxiety/stress those with BD-II and cyclothymia (Francis-Raniere et al. symptoms and hypomanic and depressive symptoma- 2006). Lam et al. (2004) found that beliefs related to