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Behavioural and Cognitive Psychotherapy, 2014, 42, 211–223
First published online 15 February 2013 doi:10.1017/S1352465812001129
The Relationship between Perfectionism and Rumination
in Post Traumatic Stress Disorder
Sarah J. Egan, Mary Hattaway and Robert T. Kane
Curtin University, Perth, Australia
Background: To date no research has investigated the link between Post Traumatic Stress
Disorder (PTSD) and perfectionism in a clinical sample. Aims: The aim of the current
study was to examine whether there is a relationship between PTSD and perfectionism. This
is important to address as many studies have demonstrated a link between other anxiety
disorders, eating disorders, depression and perfectionism. The research also aimed to examine
whether rumination was a mediator of the relationship between PTSD and perfectionism.
Method: The sample consisted of 30 participants who were currently in treatment for PTSD.
Results: The results suggest that perfectionism and PTSD symptoms were significantly
correlated. In addition, rumination was a significant mediator of the relationship between
Concern over Mistakes and PTSD. Conclusions: These findings help increase understanding
about the relationships of perfectionism and rumination in PTSD and have implications for
the treatment of PTSD.
Keywords: Post traumatic stress disorder, perfectionism, rumination, transdiagnostic.
Introduction
Population estimates report as many as 65% of individuals have experienced a traumatic event,
with 5% estimated to have experienced Post Traumatic Stress Disorder (PTSD) in their lives
(Australian Centre for Posttraumatic Mental Health, 2007). Recognizing that most people
recover in the first 3 months following trauma poses the question as to why only some people
develop PTSD? Furthermore, which factors aid and which impede recovery (Cahill and Foa,
2007)? A potentially useful line of inquiry may be to examine cognitive factors that are known
to be risk and maintaining mechanisms in order to determine the influence of these on PTSD as
they may be particularly salient processes that have been overlooked in understanding PTSD.
Rumination and perfectionism
This study examines whether cognitive processes that have been found to be elevated
across numerous disorders, namely perfectionism and rumination, are associated with PTSD
symptoms. Perfectionism is elevated in eating disorders, depression, and the anxiety disorders
of Obsessive-Compulsive Disorder, Panic Disorder, and Social Phobia (Egan, Wade and
Reprint requests to Sarah Egan, School of Psychology and Speech Pathology, Curtin University, GPO Box U1987,
Perth, WA 6845, Australia. E-mail: s.egan@curtin.edu.au
© British Association for Behavioural and Cognitive Psychotherapies 2013
212 S. J. Egan et al.
Shafran, 2011); consequently it is plausible that perfectionism is also correlated with PTSD.
To the authors’ knowledge, no research to date has investigated whether there is a relationship
between perfectionism and PTSD in a clinical sample. Rumination has also been shown to be
elevated across numerous disorders (Ehring and Watkins, 2008) and is an important variable
to consider as it has been shown to be related to both PTSD and perfectionism (Michael,
Halligan, Clark and Ehlers, 2007; Harris, Pepper and Maack, 2008). Given rumination has
been found to be related to perfectionism and PTSD, if a relationship does exist between
perfectionism and PTSD it is possible that rumination may serve as a mediator.
Perfectionism
A review has identified perfectionism as a risk and maintaining factor across anxiety disorders,
eating disorders and depression (Egan et al., 2011). Of the anxiety disorders, PTSD is an
exception, with no studies examining perfectionism in clinical samples (Egan et al., 2011).
Kawamura, Hunt, Frost and DiBartolo (2001) did find a relationship between a PTSD factor
and perfectionism; however the methodology involved a college student population and factor
derived PTSD.
Rumination has been associated with perfectionism (Flett, Madorsky, Hewitt and Heisel,
2002) and maladaptive perfectionism has been shown to be correlated with rumination and
depressive symptoms (Frost, Marten, Lahart and Rosenblate, 1990). Harris et al. (2008)
found that rumination mediated the relationship between maladaptive perfectionism and
depressive symptoms. This finding is important as those individuals scoring higher on
perfectionism reported higher depressive symptoms through a mechanism of rumination and
this suggests that it would be useful to determine whether rumination is also an important
mediator across other disorders where it is seen as an important clinical feature, such as
PTSD. O’Connor, O’Connor and Marshall (2007) found that the ruminative response style
of brooding was an important mechanism that helped to explain the relationship between
perfectionism and psychological distress. In a longitudinal study Olson and Kwon (2008)
examined the prediction of depressive symptoms over a 4-week period and found that
individuals with high self-oriented and socially-prescribed perfectionism on the Hewitt and
Flett Multidimensional Perfectionism Scale (HMPS; Hewitt and Flett, 1991) as well as
brooding rumination experienced the greatest increases in depressive symptoms over time.
It was concluded that the role of perfectionism as a diathesis for depression is dependent on
rumination and that rumination needs to be targeted in those with elevated perfectionism as
they are at risk compared to those low in rumination who did not show the same increases
in depression over time. It is thought therefore that rumination may explain how maladaptive
perfectionism contributes to future depressive symptoms. Hewitt and Flett (2002) explain that
perfectionists engage in rumination about failure. They state that individuals high on Concern
over Mistakes (CM) on the Frost Multidimensional Perfectionism Scale (FMPS; Frost et al.,
1990) may be more likely to ruminate.
Rumination
Ehring and Watkins (2008) reviewed the literature and demonstrated that rumination is
implicated in 13 different disorders, including depression, PSTD, social phobia, obsessive-
compulsive disorder, insomnia, eating disorders, pain disorder, hypochondriasis, alcohol use
PTSD and perfectionism 213
disorder, bipolar disorder and psychosis. Ehring and Watkins (2008) argue that rumination
plays a significant role in the maintenance of psychological disorders. Michael et al. (2007)
explained that rumination can maintain PTSD due to focusing on “why” and “what if”
questions instead of the actual traumatic experience, having positive metacognitive beliefs
about rumination maintaining the PTSD symptoms and cognitive avoidance of emotional
issues. A clinical example of how rumination and perfectionism is relevant in PTSD can be
considered through the example of Kate, who was in treatment for trauma following a sexual
assault. Preceding the trauma Kate described herself as being a perfectionist and having very
high standards across numerous areas of her life (e.g. work, appearance, musical performance)
and she had always excelled in her studies and work. After the trauma she reported significant
rumination over the event, focusing on why it should have happened to her, what she should
have done differently for the event not to have occurred, and rumination over feeling like a
failure as she should have done something different so as to not be in the situation. Kate also
reported feeling that she had failed to meet her standards of being in control of her life and her
emotional states, stating that she viewed the PTSD symptoms she was experiencing as a sign
of her failure to be in control and not be a “strong” person and that she should cope better.
She stated that she was also feeling like a failure as she was not performing in her work to her
standards as she was spending a lot of time ruminating over the trauma and feeling anxious. In
this case, the two processes of rumination and perfectionism appear to be maintaining factors
of her symptoms, and also to interact with each other to keep the symptoms going in a vicious
cycle.
Avoidance is a component of the diagnosis of PTSD and is an important variable in
rumination and perfectionism. Avoidance is a factor that maintains rumination and may
include procrastination, suppression of feelings, and not taking risks (Moberly and Watkins,
2006). Ehlers, Mayou and Bryant (1998) examined thought suppression and rumination as
possible perpetuating factors for PTSD. They found increases in rumination about an event,
in conjunction with suppression of memories, were strongly associated with PTSD. Negative
interpretations of intrusions, persistent medical problems, and rumination at 3 months were
the most significant predictors of PTSD symptoms at one year. They suggested rumination
may impede changes in negative appraisals of trauma events, in addition to the nature of
the trauma memory, similar to the process of thought suppression increasing reliving of
symptoms. Several other studies have found rumination to be one of the strongest predictors
of persistent PTSD (Clohessy and Ehlers, 1999; Murray, Ehlers and Mayou, 2002: Mayou,
Ehlers and Bryant, 2002).
Self-regulation models indicate that negative affect is produced when an individual feels
they are not reaching a goal they are trying to achieve (Ehring and Watkins, 2008) and
Martin and Tesser (1996) purport that rumination occurs when a goal has not been attained.
Ehring and Watkins (2008) explain that cognitive models for rumination suggest people
are “driven” by unresolved goals, with repetitive negative thoughts reflecting unattained
goals, and individuals with psychological disorders who get stuck in rumination may have
more extreme, unattainable or perfectionist goals. This conceptualization is important in
highlighting that rumination may be more likely when an individual displays inflexible
perfectionist standards, which result in unattainable goals. Consequently, this literature links
perfectionism and rumination and suggests the importance of considering the combined roles
of these processes in a range of disorders, not just depression as in studies to date (e.g. Harris
et al., 2008; Olson and Kwon, 2008; O’Connor et al., 2007).
214 S. J. Egan et al.
Rationale
Rumination and perfectionism are two important processes demonstrated to be elevated
across a range of disorders (Ehring and Watkins, 2008; Egan et al., 2011) and given that
the relationship between perfectionism and PTSD in a clinical sample remains unexamined,
the aim of this study was to examine whether perfectionism and rumination account for
PTSD symptoms. Research has not considered that PTSD and perfectionism are both related
to rumination in the same sample nor considered the relative roles of these variables.
Consequently, the purpose of this study is to ascertain if there is an association between
PTSD and perfectionism and, if so, to examine the role of rumination in the process. It was
hypothesized that perfectionism and PTSD would be significantly correlated. Additionally,
it was hypothesized that rumination would act as a significant mediator of the relationship.
The overarching aim of this research was to determine if the processes of rumination and
perfectionism are important in the prediction of PTSD symptoms in a preliminary attempt to
define their role, with a view to exploring potential intervention for these processes should
they be found to be important in explaining PTSD. If rumination and perfectionism are found
to be salient processes in PTSD this may suggest that it would be useful for future research
to examine whether targeting these processes would confer benefit in removing maintaining
factors of PTSD and comorbid disorders.
Method
Participants
There were a total of 30 participants recruited from the Western Australian Department
of Health Sexual Assault Resource Centre (SARC) which is a government public sector
agency located in Perth, Australia that provides free psychological assessment and treatment
for sexual assault. Participants consisted of clients who self-referred to the SARC, were
18 years and older (range 18–81 years), and 75% of the sample were female. Participants
were approached on a voluntary basis, including new referrals and individuals currently in
treatment over a 3-month period. Inclusion criteria were experience of a sexual trauma and
current engagement in psychological counselling at the SARC. The exclusion criterion was
less than one month since experiencing the trauma, so that individuals with Acute Stress
Disorder (ASD) were excluded from the study. Participants were not reimbursed for the study.
Measures
Personal Standards and Concern over Mistakes subscales of the Frost Multidimensional
Perfectionism Scale (FMPS; Frost et al., 1990). The FMPS is a 35-item, self-report measure
of perfectionism consisting of five subscales: (1) Concern over Mistakes (CM); (2) Personal
Standards (PS); (3) Parental Expectations (PE); (4) Parental Criticism (PC); and (5) Doubts
about Actions (DA). The sixth subscale, Organization is not included in the total perfectionism
scoring. A 5-point Likert scale is used, ranging from 1 =Strongly disagree to 5 =Strongly
agree. Higher scores indicate higher levels of perfectionism. This study used the PS and CM
subscales to measure perfectionism as these are the two scales that are most closely linked
to the clinical definition of perfectionism (Shafran and Mansell, 2001). There is extensive
PTSD and perfectionism 215
evidence supporting the reliability and validity of the scale (Enns and Cox, 2002). The internal
consistency in this study was good for both PS; alpha =.84 and CM; alpha =.90.
Clinical Perfectionism Questionnaire (CPQ; Fairburn, Cooper and Shafran, 2003) is a 12-
item self-report measure that assesses the degree to which individuals establish self-worth
through achievement of high standards, avoidance of performance related goals and feelings
of failure over the past month. A 4-point Likert scale is used, where 1 =Notatall,and4=
All the time. Higher scores indicate high clinical perfectionism. Steele, O’Shea, Murdock and
Wade (2011) investigated the CPQ in 39 women with eating disorders and found acceptable
reliability (alpha =.83), and convergent validity with the CPQ being significantly correlated
with PS (r=.73) and CM (r=.76) on the FMPS (Frost et al., 1990). The internal consistency
for the CPQ in this study was acceptable with a Cronbach’s alpha of .81.
Ruminative Response Scale (RRS) from the Response Styles Questionnaire (RSQ; Nolen-
Hoeksema, 1991). The RRS is a self-report measure of rumination. Respondents rate each
questionnaire item on a scale of ranging from 1 =Almost never to 4 =Almost always. The
RRS was criticised for some of the items being highly correlated with the Beck Depression
Inventory (Beck, Ward, Mendelsohn, Mock and Erbaugh, 1961). Treynor, Gonzalez and
Nolen-Hoeksema (2003) factor analysed the RRS, identifying the principal components of
depression and now these items are able to be removed (to make the 10 items). Thus for this
study the depression related items were removed, leaving 10 items. The 10 items selected from
the RSQ’s RRS self-report measure reflect two principle components of rumination, Reflective
Pondering and Brooding. Reflective Pondering is defined as engagement in problem-solving
to help alleviate negative affect and Brooding is considered to be thinking anxiously or
worrying, in a maladaptive fashion, over some unachieved standard (Harris et al., 2008).
Moberly and Watkins (2006) calculated the Cronbach’s alpha for the subscales of Brooding
and Reflective Pondering at .76 and .76 respectively. The internal consistency in this study
was alpha =.89 for Brooding and .67 for Reflective Pondering. The internal consistency for
the combined subscales of Reflective Pondering and Brooding of the RRS in this study was
good, with alpha =.87.
Post Traumatic Stress Checklist (Civilian) for DSM-IV (PCL-C; Weathers, Huska and
Keane, 1991) is a 17-item self-report measure of the DSM-IV symptoms for PSTD.
Respondents are asked to rate how much they were “bothered by that problem in the past
month”. Items are rated on a 5-point Likert scale ranging from 1 =Not at all to 5 =Extremely;
higher scores indicate higher levels of PTSD. This study used the recommended cut-off of 50
to indicate a diagnosis of PTSD (Weathers, Litz, Herman, Huska and Keane, 1993). The PCL
has been found to have good psychometric properties, with high internal consistency (alpha =
.96) (Keane, Brief, Pratt and Miller, 2007). Weathers et al. (1993) found test-retest reliabilities
were robust (.96). The internal consistency in this study was a Cronbach’s alpha of .89.
Procedure
Ethics approval for the study was granted by the Human Research Ethics Committee (HREC)
at Curtin University and King Edward Memorial Hospital. Clients engaging in counselling
for PTSD at SARC were offered the opportunity to complete questionnaires anonymously by
the receptionist prior to entering their appointment for counselling. Counsellors mentioned
to their clients at the end of the counselling session that the research study was taking place.
SARC also services clients at various metropolitan offices around Perth. Counsellors at these
216 S. J. Egan et al.
Table 1. Mean (and Standard Deviation) of measures of PTSD,
perfectionism and rumination
Measure Mean SD Range
PCL-C 54.17 12.19 33–82
RRS 28.57 6.87 16–39
CM 29.73 7.89 9–45
PS 24.13 5.71 13–32
CPQ 28.83 6.61 18–42
Notes: PCL-C =Posttraumatic Stress Checklist Civilian Version
(Weathers, Huska and Keane, 1991); RRS =Ruminative Response
Scale (Nolen-Hoeksema, 1991); CM =Concern over Mistakes
subscale of FMPS (Frost et al., 1990); PS =Personal Standards
subscale of FMPS (Frost et al., 1990); CPQ =Clinical Perfectionism
Questionnaire (Fairburn et al., 2003)
outreach offices offered clients the opportunity to participate in the study, with clients able
to mail back their responses in the reply paid envelope to Curtin University. The participant
information sheet was given to each participant; this outlined the aims and procedures of the
study. The second author worked at SARC as a counsellor but due to ethical issues did not
recruit her own clients to participate in the research.
Results
An adequate sample for testing the proposed model was calculated to be 30 participants. The
most complex regression model consisted of four predictors and G∗Power 3 suggested that 30
participants were required for an 80% chance of capturing a “large” relationship between the
Dependent Variable and each of the predictors (Faul, Erdfelder, Buchner and Lang, 2009). No
missing data were found and all correlation and regression assumptions were met.
Descriptive data
Means and standard deviations are displayed in Table 1. The mean that was found for PTSD
in this sample (M=54.17) slightly surpassed the Weathers et al. (1991) criteria of 50 which
indicates a diagnosis of PTSD. The sample range on the PTSD measure was from 33 to 82,
with 11 participants not reaching the criteria and 19 reaching the criteria, or 63% reaching
the cut-off for PTSD criteria. This emphasized that a majority of the population was indeed
a clinical PTSD population, and the mean score of the sample indicated that on average the
sample was in a clinical PTSD range.
Correlation analysis
A series of bivariate correlations were conducted, first in order to establish whether the
variables were significantly associated and the proposed mediation model could be tested. As
seen in Table 2, all variables were significantly associated, with the exception of PS and PTSD.
It is noteworthy that perfectionism had a strong correlation with PTSD on both measures
PTSD and perfectionism 217
Table 2. Summary of bivarate correlations for PTSD, rumination
and perfectionism measures
Measure 12 3 4 5
1. PCL-C – .68∗∗ .57∗∗ .24 .69∗∗
2. RRS – .69∗∗ .44∗.67∗∗
3. CM – .45∗.70∗∗
4. PS – .50∗∗
5. CPQ –
Notes: PCL-C =Posttraumatic Stress Checklist Civilian Version
(Weathers et al., 1991); RRS =Ruminative Response Scale (Nolen-
Hoeksema, 1991); CM =Concern over Mistakes subscale of FMPS
(Frost et al., 1990); PS =Personal Standards subscale of FMPS
(Frost et al., 1990); CPQ =Clinical Perfectionism Questionnaire
(Fairburn et al., 2003), ∗p<.05,∗∗p<.01, two tailed.
Table 3. Unstandardized (B) and standardized (β) regression coefficients and
squared-semi partial correlations (sr2) for each predictor in the regression models
predicting rumination and PTSD for the CPQ (N=30)
Var i a b le B[95% CI] SE βsr2p
RRS (DV)
CPQ .70 [.397, .995] .15 .67 .45 .001∗∗
PTSD (DV)
RRS .70 [.074, 1.323] .30 .39 .29 .03∗
CPQ .79 [.138, 1.436] .32 .43 .32 .02∗
Notes: PCL-C =Posttraumatic Stress Checklist Civilian Version (Weathers et al., 1991);
RRS =Ruminative Response Scale (Nolen-Hoeksema, 1991); CM =Concern over
Mistakes subscale of FMPS (Frost et al., 1990); PS =Personal Standards subscale of
FMPS (Frost et al., 1990); CPQ =Clinical Perfectionism Questionnaire (Fairburn et al.,
2003), p<.05; ∗∗ p<.01; ∗∗∗ p<.001. SE =Standard Error, CI =Confidence Interval
of clinical/negative perfectionism, on CM (r=.57) and the CPQ (r=.69). It can also be
seen that the relationship between PTSD and rumination was strong (r=.68). Furthermore,
there was also a significant association between rumination and all perfectionism measures.
This indicates, as hypothesized, that significant relationships do exist between the variables
of PTSD, perfectionism and rumination.
Standard multiple regression analyses and mediation models
In order to determine the beta-weights of the proposed mediation model for the two
perfectionism measures, a series of two-step standard multiple regression analyses were
conducted, as seen in Tables 3 and 4. As PS was not correlated with PTSD it was not added
to the standard multiple regression analyses.
The following set of standard regression analyses used the CPQ as the perfectionism meas-
ure to determine the beta-weights to test the proposed rumination mediation model between
the perfectionism and PTSD relationship. Rumination was the dependent variable in the first
218 S. J. Egan et al.
.669
,
p
= .000 .393
,
p
= .030
PTSD
(PCL-C)
Rumination
(RRS)
Clinical
perfectionism
(CPQ)
.427, p = .019
Figure 1. Model for rumination as a mediator between clinical perfectionism and PTSD
regression analysis for the predictor CPQ. Clinical perfectionism accounted for a significant
45% of the variance in rumination, R2=.45, adjusted R2=.43, F(1, 28) =22.74, p=.0001.
The second regression analysis placed PTSD as the dependent variable and rumination and
CPQ as predictors. Rumination and the CPQ accounted for a significant 56% of the variance
in PTSD, R2=.56, adjusted R2=.53,F(2, 27) =17.32, p=.0001. Unstandardized (B) and
standardized (β) Regression Coefficients and Squared-Semi Partial (or “part”) correlations
(sr2) for each predictor in the regression models are reported in Table 3.
The next step was to apply the path coefficients generated by the aforementioned regression
analyses to the mediation model as can be seen in Figure 1. The beta weights (i.e. the
standardized regression weights) for the predictors provided the path coefficients. The
model displayed in Figure 1 revealed that significant pathways exist between the CPQ and
rumination, the CPQ and PTSD, and rumination and PTSD. Given that a significant direct
pathway existed between the CPQ and PTSD it can be concluded that rumination does not
fully mediate the relationship between the CPQ and PTSD. The next step was to determine
the impact of rumination on the CPQ and PTSD. In order to test the mediation model Sobel’s
test statistic (Sobel, 1982) was used. The test was significant, z=2.087, p=.036, indicating
a partial mediation (Baron and Kenny, 1986).
Rumination was the dependent variable in the first regression analysis when CM was the
predictor. CM accounted for a significant 47% of the variance in rumination, R2=.47,
adjusted R2=.45,F(1, 28) =25.03, p=.0001. The second regression analysis placed
PTSD as the dependent variable and rumination and CM as predictors. Rumination and CM
accounted for a significant 48% of the variance in PTSD, R2=.48, adjusted R2=.44, F (2,
27) =12.59, p=.0001. Unstandardized (B) and standardized (β) Regression Coefficients and
Squared-Semi Partial (or “part”) correlations (sr2) for each predictor in the regression models
are reported in Table 4.
Following these regression analyses the next step was to again apply the path coefficients
to the mediation model. The model displayed in Figure 2 revealed that significant pathways
exist between CM and rumination, rumination and PTSD, but not for CM and PTSD. Given
that a nonsignificant pathway existed between the CM and PTSD, it can be concluded that
rumination fully mediated the relationship between CM and PTSD.
Discussion
The hypothesis that there would be a significant relationship between PTSD and perfectionism
was supported. In addition, it was found that rumination was a mediator of the relationship
between PTSD and perfectionism when measured using the CM subscale of the FMPS
PTSD and perfectionism 219
Table 4. Unstandardized (B) and Standardized (β) regression coefficients and
squared-semi partial correlations (sr2) for each predictor in the regression models
predicting rumination and PTSD for the CPQ, (N=30)
Var i a b le B[95% CI] SE βsr2p
RRS (DV)
CM .60 [.353, .843] .12 .69 .47 .001∗∗
PTSD (DV)
RRS .96 [.267, 1.655] .34 .54 .16 .008∗
CM .31 [−.294, .913] .29 .20 .02 .30
Notes: PCL-C =Posttraumatic Stress Checklist Civilian Version (Weathers et al., 1991);
RRS =Ruminative Response Scale (Nolen-Hoeksema, 1991); CM =Concern over
Mistakes subscale of FMPS (Frost et al., 1990); PS =Personal Standards subscale of
FMPS (Frost et al., 1990); CPQ =Clinical Perfectionism Questionnaire (Fairburn et al.,
2003), p<.05; ∗∗ p<.01; ∗∗∗ p<.001. SE =Standard Error, CI =Confidence Interval
.542, p= .008
PTSD
(PCL-C)
Rumination
(RRS)
CM
.687, p= .000
.200, p = .302
Figure 2. Model for rumination as a mediator of Concern over Mistakes and PTSD
(Frost et al., 1990). Consequently, results supported the hypothesis that perfectionism would
be a significant predictor of PTSD symptoms, but this relationship would be mediated by
rumination.
Implications
To the authors’ knowledge, this is the first study to date to show a relationship between
perfectionism and PTSD in a clinical sample, and this was using both the CM subscale of
the FMPS (Frost et al., 1990) and the CPQ (Fairburn et al., 2003). This finding is consistent
with Egan et al.’s (2011) review of perfectionism where CM is associated with symptoms
across many disorders, and gives further evidence to this aspect of perfectionism being a
transdiagnostic process. The finding that PS was not associated with PTSD symptoms is
also consistent with Egan et al.’s review that showed PS is generally not associated with
anxiety disorder symptoms. Moreover, the results lend support to the notion of PS being not
consistently associated with psychopathology, and the distinction between PS representing
“positive striving” and CM representing “maladaptive evaluative concerns” (see Stoeber and
Otto, 2006 for a review).
The general pattern of significant bivariate correlations existing across most measures
is noteworthy as it highlights the related and to some degree overlapping nature of the
variables. The processes of rumination and perfectionism are associated, and both of these
220 S. J. Egan et al.
processes are also associated with PTSD symptoms. The finding of a significant relationship
between rumination and PTSD is consistent with previous research (Michael et al., 2007). The
finding that rumination and perfectionism were significantly correlated also supports previous
research (Flett et al., 2002).
Rumination did fully mediate the relationship between perfectionism and PTSD, when the
CM subscale of the FMPS (Frost et al., 1990) was used, but not when the CPQ (Fairburn
et al.,2003) was utilised as the measure of perfectionism. The finding that rumination acted
fully as a mediator with CM but not the CPQ in PTSD requires examination. This finding may
indicate the CPQ warrants further work on validity as a measure of perfectionism. The FMPS
scales are a widely used and validated measure of perfectionism, while evidence supporting
the validity of the CPQ is scant. Hewitt and Flett (2002) have explained that perfectionists
engage in rumination about failure; hence perfectionists high on Concern over Mistakes are
likely to ruminate. The current result of rumination acting as a mediator between CM and
PTSD is therefore in keeping with this previous research. The results are also consistent with
rumination being found as a mediator between maladaptive perfectionism and depressive
symptoms (see Harris et al., 2008) and the brooding ruminative response style mediating
perfectionism and psychological distress (O’Connor et al., 2007). The findings overall lend
support to the rationale of both perfectionism and rumination acting as transdiagnostic
processes across different disorders (Egan et al., 2011; Ehring and Watkins, 2008).
Limitations of the study
The following limitations are acknowledged. First, the sample consisted of sexual violence
survivors who may compose a unique interpersonal trauma population compared to that of
other traumas. Second, the study was voluntary and it is possible that the sample selection
is biased; for example, individuals with higher degrees of perfectionism may have chosen to
participate in the study. Third, the internal consistency of the Reflective Pondering scale was
poor (Cronbach’s alpha of .67). Finally, as only 63% of the sample had a diagnosis of PTSD,
it may be useful in the future to restrict a further sample to only those who meet a diagnosis
of PTSD. Despite this, the mean score of the sample was in a clinical PTSD range, and as it
was a preliminary study, it was useful to include all cases including those that did not fully
reach diagnostic criteria.
A major limitation of the study was that a cross-sectional design was utilised and while the
results are useful in identifying correlations between variables, causal statements regarding
the relationship between perfectionism, rumination and PTSD cannot be made. This was a
preliminary attempt to establish whether relationships exist. However, in the context of the
data being cross-sectional, conclusions need to be interpreted with caution as the design limits
the interpretation of the mediation models, as they do not show temporal precedence. It is
unclear whether perfectionism predicts rumination or vice versa, and thus future longitudinal
research is required to determine the direction of these relationships.
Strengths of the study
The aim to investigate whether a relationship existed between perfectionism and PTSD in
a clinical sample addressed a significant gap in the literature. In addition, it was the first
study to date to investigate rumination as a mediator of the relationship. The present results
PTSD and perfectionism 221
may be useful in suggesting future research in to the role of perfectionism and rumination
in PTSD and if intervening with these processes may potentially be useful in treatment for
PTSD.
Future directions
In terms of understanding the relationship between rumination, perfectionism and PTSD,
future research could aim to investigate whether perfectionism has a unique contribution to the
relationship between perfectionism and PTSD. This could be achieved by using a measure of
PTSD related rumination as a dependent variable, and to include perfectionism measures, in
addition to other important variables including responsibility and self-esteem as independent
variables, with a larger sample. It would be useful also if possible to conduct longitudinal
research to determine if levels of perfectionism preceding a trauma can account for greater
likelihood of development of PTSD symptoms post trauma. Despite this being a difficult study
to conduct as it needs to follow people pre- and post-trauma, it may be possible to conduct
the research within groups where there are more frequent experiences of trauma (for example
emergency workers).
It would also be useful for future research to examine the content of rumination in PTSD to
determine if this is specific to PTSD rather than the typical rumination pattern in depression.
For example, it would be useful to determine if perfectionism is related to specific trauma-
related negative appraisals.
The clinical implications of this research indicate that a useful direction for future research
would be to investigate interventions for the relationship between perfectionism and PTSD,
and the additional impact of rumination that this study has established. This may be important
given that perfectionism has been shown to be a maintaining factor for other disorders, and
also impedes treatment (Egan et al., 2011). Furthermore, the preliminary findings from this
study suggest that it would be useful for future research to determine whether targeting
rumination and perfectionism in PTSD treatment is effective. Treatments exist for both of
these processes but as far as the authors are aware there have not been any studies for
treatment of perfectionism in PTSD. There has been some research examining the treatment
of rumination in PTSD; for example Wells (2009) described a treatment using metacognitive
therapy to address rumination in PTSD. This encompasses analysing the advantages and
disadvantages of rumination, with provision of training to acknowledge symptoms as they
are occurring, referred to as detached mindfulness and rumination/worry postponement.
Further research is required on the effectiveness of this approach, and it would be useful
to investigate if also targeting perfectionism may lead to further amelioration of PTSD
symptoms.
Conclusions
If future studies, using prospective designs, confirm the relationship between perfectionism
and PTSD and if treatments that target perfectionism and rumination are found to lessen the
impact of PTSD, then this research may potentially help to increase treatment efficacy in
PTSD.
222 S. J. Egan et al.
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