Perfectionism

1. CBT for Clinical Perfectionism
Roz Shafran, Ph.D.
Professor of Translational Psychology
UCL Institute of Child Health and Great Ormond Street

2. Agenda

3. Flexible Plan
BEFORE TEA BREAK: Agenda setting, theory, exercise 1
BEFORE LUNCH: Empirical status, assessment, formulation,
treatment overview, exercise 2
AFTER LUNCH: Problematic behaviour, rules and standards,
cognitive biases, exercise 3
LAST BIT:
Dysfunctional beliefs, dysfunctional scheme for self-evaluation, relapse
prevention, exercise 4
Summary and feedback

4. Background: Healthy vs. unhealthy
• Normal vs. neurotic
• Functional vs. dysfunctional
• Healthy vs. unhealthy

5. • “Tyranny of the shoulds” (Horney, 1950)
• “Musterbation” (Ellis, 1961)
• “Those whose standards are high beyond reach or reason,
people who strain compulsively and unremittingly toward
impossible goals and who measure their own worth entirely in
terms of productivity and accomplishment” (Burns, 1980)
• “Setting of excessively high standards for performance
accompanied by overly critical self-evaluation (Frost, Marten,
Lahart & Rosenblate, 1990)
• “Multidimensional” (Hewitt & Flett, 1991)
Definitions

6. Ways in which perfectionism is
problematic

7. 1. Significant clinical problem in its own
right
• Time
• Social isolation
• Performance anxiety
• Narrowing of interests
• Low mood
• Procrastination/avoidance
• Unemployment/drop out of studies

8. 2. Impact on treatment: Depression
National Institute of Mental Health Treatment of
Depression Collaborative Research Program (TDCRP)
– Dysfunctional perfectionism was associated with higher pre-
treatment levels of depression and greater impaired adjustment at
the end of treatment (Blatt, Quinlan, Pilkonis and Shea (1995) and
Shahar et al. (2003))
– Smaller or absent increases in therapeutic alliance compared with
those low in perfectionism (Zuroff, Blatt, Sotsky, Krupnick, Martin,
Sanislow, & Simmens (2000))
• Treatment for Adolescents with Depression Study
(n=439).
– Higher perfectionism scores at baseline had higher depression
during treatment period
– Perfectionism impeded improvement in suicidality
– Treatment outcomes partially mediated by change in
perfectionism
(Jacobs et al., 2009)

9. Impact on treatment: eating disorders
• Sutandar-Pinnock, Woodside, Carter, Olmsted &
Kaplan (2003). Negative impact on treatment
outcome for anorexia nervosa
• Steele, Bergin & Wade (2011). Higher levels of
perfectionism at baseline resulted in less
reduction on the EDE global score when treating
bulimia nervosa using guided self help.

10. Impact on treatment: OCD
• Perfectionism (as part of obsessive compulsive
personality disorder) predicted worse treatment
outcome for exposure and response prevention
for 49 patients with OCD, 17 of whom met OCPD
criteria
Pinto, Liebowitz, Foa & Simpson (2011). Obsessive compulsive personality disorder as a predictor
of exposure and ritual prevention outcome for obsessive compulsive disorder. Behaviour Research
and Therapy, 49, 453-8.

11. BUT
• Mussell et al. (2000). Outcome for bulimia nervosa not predicted by
pre-treatment levels of perfectionism
• Lundh & Ost (2001) and Rosser et al. (2003). Perfectionism not
predict outcome for social phobia
• Perfectionism changes as a result of successful treatment of social
phobia (Ashbaugh et al., 2007) and anxiety in children (Mitchell et al.,
2013).

12. 3. Associations with other forms of
psychopathology
• Hewitt & Flett (2002)
• Egan, Wade & Shafran (2011). Clinical
Psychology Review.
– Depression
– Anxiety
– Chronic Fatigue
– Suicidal ideation
– Eating disorders

13. • http://www.youtube.com/watch?v=04S5oxzoLqg
• http://www.youtube.com/watch?v=bgeLislRCko

14. 4. Risk factor
• Development of anorexia
nervosa and bulimia nervosa
(Fairburn et al. 1999; Bulik et al.,
2003)
• Depression. Hewitt, Flett &
Ediger (1996)

15. Treatment issues
1. If perfectionism is a long term personality
problem, do we need a long term personality-
based treatment????
2. Which aspects of perfectionism
should be treated?
• Personal standards
• Socially oriented
• Other oriented
• Doubts about actions
• Concern over mistakes?

16. Treatment Advances
• Interplay of theory – experiments – treatment
experiments (Salkovskis, 2002; Clark, 2004)
• Biggest treatment advances come from focusing on
reversing putative maintaining mechanisms
– Panic disorder (NICE, 2005)
– Bulimia nervosa (NICE, 2004)
• Don’t try to do too much all in one go!

17. “Clinical Perfectionism”
Shafran, R., Cooper, Z. &
Fairburn,
C. G. (2002). Clinical
Perfectionism:
a cognitive behavioural analysis.
Behaviour Research and
Therapy, 40, 773-791.

18. • Self-imposed nature of standards
• Standards are personally
demanding
• Self-worth dependent upon success
and achievement
• Attention to failures at expense of
successes
• Self-defeating

19. Original analysis
• Construes clinical perfectionism as a dysfunctional
scheme for self-evaluation.
• Core psychopathology as the overdependence of
self-evaluation on the determined pursuit of
personally demanding, self-imposed standards in at
least one highly salient domain despite adverse
consequences

20. Context
• Type of perfectionism seen in clinical practice
• Not:
– Positive healthy striving
– Having high standards for other people
– Believing that others have high standards for
you
• Hypothesised maintaining mechanism for eating
disorders (Fairburn, Cooper & Shafran, 2003)

21. Self-worth overly dependent on striving
and achievement
Set standards
Cognitive biases
Fail to meet standards Temporarily meet standards
Self-criticism Reappraise standards as
insufficiently demanding
Adverse consequences:
Positive consequences:
(Re)

22. Self-worth overly dependent on striving
and achievement
Set standards
Cognitive biases
Fail to meet standards Temporarily meet standards
Emotional
distress,
Counter-
productive
behaviour and
Self-criticism
Reappraise standards as
insufficiently demanding
Adverse consequences:
Positive consequences:
(Re)
Performance related
behaviour/emotion
Avoid/
procrastinate

23. Hypotheses
• Clinical perfectionism is maintained by
– Dysfunctional expressions of core psychopathology
e.g., repeated checking
– Rigid standards expressed as rules
– Cognitive biases
• Biased evaluation of performance
• Discounting success
• Resetting standards
– Negative self-evaluation, self-criticism and fear of
‘failure’

24. Hypotheses
• Clinical perfectionism will impede the successful
treatment of Axis I disorders if the domains overlap
• Eating disorders can sometimes be an expression of
clinical perfectionism in the domain of eating, shape and
weight

25. Treatment implications
1. A personalised formulation in terms of clinical
perfectionism
2. Broadening the patient’s scheme for self-evaluation
3. Using behavioural experiments to test competing
hypotheses
4. Using cognitive-behavioural methods to address
personal standards, self-criticism and cognitive biases
that maintain clinical perfectionism

26. Reaction to theory
Self Other
Social
‘Multi
dimensional’
Long term treatment needed

27. Response
•Highly specific construct
•Not ‘either’ ‘or’ but different concepts
•Proof of pudding is in clinical utility

28. Exercise 1
• In pairs, choose a client for whom:
– Clinical perfectionism has been a problem in its own right
OR
– Clinical perfectionism has appeared to interfere with
treatment progress
• Discuss which aspects of the model might be
relevant for this person
• 5 minutes
• Feedback to larger group

29. Empirical evidence

30. Can we treat perfectionism?
• Temperament generally considered to be
stable over lifetime
• 9%-49% of Frost measures heritable
• Infers perfectionism can be manipulated

31. Early investigations
• Ferguson and Rodway (1994): case series study (N =9), identifying
automatic thoughts and restructuring cognitive distortions into positive
coping statements
– reduction of perfectionism using “Self-Anchored Scale”, conclusions
were based solely on “visual analysis” of the data, with no formal
statistical analyses
• DiBartolo, Frost, Dixon and Almodovar (2001): 60 female
undergraduate students received either a brief (8 minutes) cognitive
restructuring intervention or a distraction intervention prior to delivering
a speech in front of a small audience
– Cognitive restructuring was successful in reducing evaluative threat
concerns and associated with lower self-reported anxiety compared
to participants in the distraction condition.
• Shafran, Lee, Payne and Fairburn (2006): experimental manipulations
of personal standards resulted in changes in eating behaviours in non-
clinical individuals
– higher personal standards associated with increased restraint and
regret after eating
• Single-case studies
– Hirsch and Hayward (1998)
– Shafran, Lee, & Fairburn (2004)

32. Year 10 girl allocated to
perfectionism (N=51); media
literacy (N=43); control (classes
as normal; N=44)
– 8 lessons
– Pre-, post- and 3-month follow-
up
– Content based on
“Perfectionism: What’s bad
about being too good?” by
Adderholdt & Goldberg (1999)
– Main effect of group for
reduction of concern over
mistakes favouring the
perfectionism group at 3-month
follow-up
• Wilksch SM, Durbridge M, Wade TD.
(2008). A preliminary controlled
comparison of programs designed to
reduce risk for eating disorders
targeting perfectionism and media
literacy. Journal of the American
Academy of Child and Adolescent
Psychiatry, 47, 939-947.
Recent evaluations

33. • 49 people responded to
newspaper/radio calls as experienced
problems with perfectionism,
randomised to 8-week treatment:
– GSH: face to face sessions (N=8)
– PSH: book
• Significant time x group interactions
favouring GSH for measures of
obsessionality
– Both treatments showed significant main
effect of time for perfectionism variables
with large effect sizes
• Pleva J, Wade TD. (2007). Guided self-help
versus pure self-help for perfectionism: a
randomised controlled trial. Behaviour
Research and Therapy, 45, 849-861.
When Perfect Isn’t Good Enough

34. Clinically significant change
0
10
20
30
40
50
60
CM PS DA
GSH
PSH

35. More recent evaluations
• N = 20 participants; high scorers on the Clinical
Perfectionism Examination and the Clinical Perfectionism
Questionnaire (Fairburn, Cooper, and Shafran)
• CBT treatment vs. a wait-list control condition
• Treatment = 10 sessions of individual CBT over 8 wks
• Treatment gains e maintained at 8- and 16-week follow-up
• Ten participants met criteria for an anxiety disorder or
major depressive episode immediately prior to treatment,
reducing to four participants at 16-week follow up
• Riley, C., Lee, M., Cooper, Z., Fairburn, C.G., & Shafran, R. (2007). A
randomised controlled trial of cognitive-behaviour therapy for clinical
perfectionism: A preliminary study. Behaviour Research and Therapy, 45,
2221-2231

36. More recent evaluations
Three GSH interventions for BN, 8 individual outpatient
sessions (20 to 50 minutes), 6-week period, novice
therapist
– 48 clients, 11 drop-outs (23%)
• CBT for perfectionism - 11.8%
• CBT for BN – 26.7%
• Dismantled mindfulness – 37.5%
– No significant time × treatment interactions or main effects for group
– Significant main effects for time for 8/12 outcome variables
excluding use of laxatives and diuretics, depression, anxiety and
personal standards perfectionism
– Within-group effect sizes ranged from .39 to 5.93.
• Steele AL, Wade TD. (2008). A randomised trial investigating guided self-help to
reduce perfectionism and its impact on bulimia nervosa. Behaviour Research and
Therapy, 46, 1316-1323.

37. Case-series design
• N=21
• Compared psychoeducation and group CBT for
perfectionism
• Group CBT for clinical perfectionism was
beneficial, but that psycho-education alone was
not effective for reducing perfectionism or
negative affect.
Steele, A. L., Waite, S., Egan, S. J., Finnigan, J., Handley, A., & Wade, T. D. (2013). Psycho-education
and group cognitive-behavioural therapy for clinical perfectionism: a case-series evaluation. Behavioural
and cognitive psychotherapy,41(02), 129-143.

38. Low Intensity Treatment
• n=77 participants high in perfectionism
• Randomized to 10 weeks of:
– No treatment
– General Stress Management
– CBT
CBT > General Stress Management or no treatment
Changes in perfectionism significantly correlated with
changes in depression and anxiety
Arpin-Cribbie, Irvin & Ritvo (2012). Psychotherapy Research. Web-based cognitive-behavioral
therapy for perfectionism: a randomized controlled trial., 22, 194-207

39. Assessment

40. Assessment
1) Clinical interview
2) Semi-structured, standardized
interview (Clinical Perfectionism
Examination)
3) Clinical Perfectionism Scale (Fairburn,
Cooper & Shafran, 2003)
4) Frost Multidimensional Perfectionism
Scale (Frost et al., 1991)
5) Hewit & Flett Multidimensional
Perfectionism Scale (Hewitt & Flett,
1991)

41. Assessment
• DVD

42. Assessment
Case Conceptualisation

43. “Holy self hatred”
¶ Make a supreme effort to root out self-love from your heart and to plant in its
place this holy self-hatred. This is the royal road by which we turn our
backs on mediocrity, and which leads us without fail to the summit of
perfection.
Saint Catherine of Sienna, 1347-1380

44. • Use theory to make explanatory inferences
about maintaining factors that can inform
interventions
• At heart of conceptualisation related to
perfectionism:
– Over-evaluation of striving and achievement usually
in context of low self-worth in other domains

45. A parsimonious approach
• Describe person’s presenting problems with
least number of explanatory variables required
in terms of:
– core beliefs, assumptions, automatic thoughts
– emotional reactions
– behavioural aspects of the problems
– behavioural strengths and deficits
– social factors that influence the problem (past &
present)
– biological factors

46. Process not Diagnosis
• The conceptualisation that arises from the
assessment process (not diagnosis) is
– important for the formulation and justification of
treatment plans and developing some hope and
expectation for change
– explicitly shared with the client, in order to promote a
collaborative relationship
– revised over the course of therapy as new information
arises and the client feels comfortable to share further
information
– vicious cycle, showing how the problem can take on a
life of its own after a triggering event, and
communicates that the cycle can be broken by
making gradual changes to its component parts

47. Formulation
• Based on model but personalised
• Heart is overevaluation of striving and achievement

48. Treatment overview

49. Treatment based on theory
• Developed by Centre for Eating Disorders and Obesity for
use within “transdiagnostic” treatment of eating disorders
(Fairburn, Palmer et al.)
• Expanded after case-series to form a 10 session
treatment
• Goal: stand-alone intervention or adjunct to evidence-
based treatment if clinical perfectionism seen as a barrier
to change

50. Overview of treatment
• Range of procedures available for addressing the over-
evaluation of performance and its various expressions
• The choice of procedures to use and the best order in
which to implement them depends on the particular
problems
• Ongoing reassessment is important
• Simpler interventions first
• Importance of objective examination of thoughts, feelings
and behaviours

51. General Points
• Same as “transdiagnostic” treatment i.e.,
– Focuses on maintaining mechanisms, not aetiology
(unless needed)
– Personalised formulation is developed and evolves
– Strong emphasis on behaviour change
– Parsimony in use of interventions
– Homework setting
– Treatment ends with focus on the future
• Manual describes the principles and methods of
treatment and should be used flexibly

52. Structure across sessions
• 10 sessions over 8 weeks
• First six sessions bi-weekly
• Next 3 sessions weekly
• Fortnight’s gap between sessions 9 & 10
ENGAGEMENT

53. Structure within sessions
(Fairburn, Marcus & Wilson, 1993)
Review homework (5 mins)
Agree agenda (2 mins)
Work way through agenda (35
mins)
Agree homework (3 mins)
Summarise session (5 mins)

54. Structure within sessions
(Fairburn, Marcus & Wilson, 1993)
A note about homework!
• Patients can be over-thorough
• Frequently fear that it will be
“wrong”
• Black and white thinking – if can’t
do perfectly, won’t do at all

55. Exercise 2
• Read the case of ‘Charlene’
• What questions would you like to ask to further
assess her perfectionism and her anxiety?
• What relationship may there be between her
perfectionism and anxiety? How could you
assess this?
• Treatment ideas?
• Feedback to the larger group
• Remaining time until lunch

56. Content
1. Cognitive-behavioural formulation
2. Psychoeducation & monitoring
3. Decreasing problematic behaviour
4. Rigidity, rules and extreme standards
5. Cognitive biases
6. Dysfunctional Beliefs
7. Problem-solving (including relaxation/time
management strategies)
8. Dysfunctional scheme for self-evaluation
9. Relapse prevention
NB Personalised!

57. 1. Personalised Formulation
• Based on analysis of clinical perfectionism

58. 2. Monitoring & psychoeducation
• Repeated performance checking
– Magnifies the relevant concerns
– Maintains negative self-evaluation in general.
– Can focus attention on the aspects of the tasks
causing most anxiety which serves to maintain (and
possibly increase) preoccupation.
– Decreases confidence in memory
• Avoidance/procrastination
– avoiding tests of performance results
“fearing the worst” and having direct adverse
consequences e.g., not sitting an exam.

59. 2. Monitoring & psychoeducation
• Counterproductive ‘safety behaviour’
– Making lists
– Multi-tasking
– Ensuring that ‘everything is in place’ before the
patient begins a task
– Can maintain other beliefs such as ‘I’m stupid – if I
don’t write everything down, I’m bound to make a
mistake.’
• Nature of anxiety
• Formulation-psychoeducation-monitoring-formulation
i.e., evolving and dynamic

60. Stress and Performance
Performance
Stress
Zone of optimum
performance

61. Self-criticism
• Consistent pattern from 5 studies of negative
association between self-criticism and goal
progress. The results also showed a positive
association between self-oriented perfectionism
and goal progress when self-criticism was
controlled
Powers, Koestner, Zuroff, Milyavskaya & Gorin (2011). The effects of self-
criticism and self-oriented perfectionism on goal pursuit Personality and
Social Psychology Bulletin, 37, 964-75.

62. Monitoring problematic behaviour
• Real-time
• Anticipate any difficulties
• Emphasise importance
• First thing go through subsequent
session

63. 3. Decreasing problematic behaviour

64. Behavioural experiments
• Range of methods available (Bennett-
Levy et al, 2004)
• ‘Contrast’ experiments particularly
helpful for repeated checking
• Hypothesis-testing & discovery
experiments
• Personally salient

65. Surveys
• “Discovery experiment”
• For Carol, asked other people about their standards for
parenting e.g., how much chocolate/treats they allowed
their children





66. Specific methods
•
• Decreasing pathological checking
• “Surfing” the urge
• “habit reversal” (Azrin and Nunn, 1973)
• Specific understanding of reason for checking
is vital
• Decreasing procrastination and avoidance of
tests of performance
– http://www.youtube.com/watch?v=4P785j15Tzk
• Decreasing ‘safety behaviour’

67. Specific methods
•
• Decreasing pathological checking
• “Surfing” the urge
• “habit reversal” (Azrin and Nunn, 1973)
• Specific understanding of reason for checking
is vital

68. Patient Report
“Why do I check so much? I guess it’s because
so many things can go wrong. And things going
wrong always seem worse to me than to other
people. If something bad happened and I didn’t
check properly, I would feel so awful – even more
awful because for most of the things I check, no
one else would ever bother to check them, so it
would definitely be my fault if something
happened.”

69. Cognitive Model of Compulsive Checking (Rachman, 2002)
Perceived
Responsibility
Perceived
Probability of
Harm
Perceived
Seriousness of
Harm
Anxiety
Engage in
Preventative
Checking
SELF-PERPETUATING
MECHANISM
- Check raises responsibility
- Check impairs meta-memory
- Check increases danger
Behaviour - out of
control
-----
Impaired
meta-memory
MEANS
That
•I am abnormal
•I am deteriorating
•I am a failure etc.
I need to be
especially
careful
X X

70. Targets of treatment
• Multipliers
– Perceived responsibility, probablity and seriousness
harm
• Self-perpetuating mechanism
• Are there relationships between checking,
memory and metamemory?

71. van den Hout & Kindt (2003a, 2003b, 2004)

72. Radomsky, Gilchrist and Dussault (2006)

73. Checking
• Did you eat breakfast this morning?
– What did you have?
• Did you eat breakfast on January 10th 1992?
– What did you have?
• Repetition, salience, each check adds to your set
of experiences, making individual episodes
difficult, if not impossible to recall vividly, with
detail or with confidence

74. The more you do it (i.e., check),
• The less confident you are in your memory
– (Memory accuracy is unaffected)
• Beliefs about memory may be key
• Consistent with this approach are decreases in
confidence in attention, confidence in perception,
etc.

75. Behavioural experiment

76. 4. RIGIDITY, RULES AND EXTREME
STANDARDS
• Rules vs. guidelines: Relax rules
• Behavioural experiments
– E.g., reducing the amount of time
allocated to an assignment
– Go by ‘80:20’ rule of thumb whereby 80% of outcome
takes 20% of effort, and extra 20% of outcome takes
80% effort
• All-or-nothing thinking
• ‘Acceptance’
• Things one cannot change, one has to learn to accept as
positively as possible. Doing so is a sign of strength and
a process of self-affirmation, not passive resignation to
an unhappy fate (Wilson).
• ‘Pros and cons’ in the context of self-evaluation

77. Exercise

78. Exercise 3: YES OR NO
Rule Guideline
Flexibility?
Usually consists of ‘must’ statements
Frequently contains words such as ‘sometimes’ and ‘try’
After breaking the person feels….

79. Exercise 3 ctnd: Tranfsform rule into
guideline
• I must always eat before 7 p.m.
• I should always put my friends’ needs before my
own
• It is essential to always make sure the dishes are
spotless
• I can never be late

80. Exercise 3: Last part
Have a specific person/patient in mind. What rule
do you think it would be helpful to transform into
a guideline and how would you think about doing
it?

81. The home straight…..

82. 5. COGNITIVE BIASES
1.Selective attention
2. Discounting positive aspects of performance
3. Double standards and accompanying self-
criticism
4. Overgeneralisation
5. Dichotomous appraisal of performance/ ‘all
or nothing’ thinking/ ‘black and white thinking’
Standard techniques e.g., positive data log, continua,
cognitive restructuring

83. 5. COGNITIVE BIASES
1.Selective attention -
http://www.youtube.com/watch?v=Ahg6qcgoay4
2. Discounting positive aspects of performance
3. Double standards and accompanying self-
criticism Coach analogy (Hofmann & Otto)
4. Overgeneralisation
5. Dichotomous appraisal of performance/ ‘all
or nothing’ thinking/ ‘black and white thinking’
Standard techniques e.g., positive data log, orthogonal and
ordinary continua, cognitive restructuring

84. 6. Dysfunctional assumptions/beliefs
• The harder I work, the better I’ll do
• I’m stupid so I need to work harder than others
• If I ‘slack’ one time, it will be a slippery slope to
complete failure
• I should always be productive
• I should never ‘waste time’
• I should continually strive to better myself
• I should do things thoroughly
• I should leave as little time as possible for tasks so I
don’t ‘waste time’ (even if I’m late)
• I should never be late
Behavioural experiments
Cognitive restructuring

85. 6. Dysfunctional assumption
“I should have perfect control over my children’s
behaviour otherwise people will judge me
negatively”

86. 7. Problem-solving, relaxation, time-
management

87. 7. Problem-solving, relaxation, time-
management
• On as ‘as-needed’ basis
• Problem-solving as described by Fairburn (1995)
– Identify the problem early
– Specify the problem precisely (one problem!)
– Brainstorm all possible solutions
– Evaluate the solutions
– Implement a solution or solutions
– Evaluate the solution chosen

88. 8. Overevaluation of striving &
performance
• A historical review of the origins and
development of the over-evaluation
• Continuing to addressing the cognitive
processes currently maintaining the over-
evaluation and facilitating the patient’s
awareness of the scheme and its expressions
• Directly altering the patient’s self-evaluation
scheme via pie-charts

89. 9. Maintenance and relapse prevention
• Maintenance plan
• Purpose to summarise what has been
done in treatment and prepare for future
• Includes distinguishing between lapse &
relapse
• Anticipating situations that might lead to a
setback

90. Final exercise

91. Exercise 4
• On your own, list the areas that contribute to your self-
evaluation
• Draw a pie-chart to reflect the relative contribution of
each area to your self-worth
• If you think that you have too many eggs in one basket,
then consider which areas you would like to expand,
and which new areas you might want to add
• Consider one practical thing you can do to begin to
broaden your own domains
• Feedback if you wish

92. Summary

93.  Flett, G.L., & Hewitt, P.L. (2002).
Perfectionism: Theory, research, and
treatment. Washington, DC:
American Psychological Association.
 Antony, M.M., & Swinson, R.P.
(2009). When perfect isn’t good
enough: Strategies for coping with
perfectionism (2nd ed.). Oakland, CA:
New Harbinger Publications
 Overcoming Perfectionism by Roz
Shafran, Sarah Egan, and Tracey
Wade (Paperback - 25 Mar 2010)
 Egan, S,J., Wade, T. D., Shafran, R.,
& Antony, M. M. (2014). CBT of
Perfectionism. Guildford Press. .
Further reading