The World Journal of Biological Psychiatry, 2010; 11(2): 476
485

ORIGINAL INVESTIGATION

Longitudinal study on perfectionism and sleep disturbance

MARIA HELENA AZEVEDO1, SANDRA CARVALHO BOS1, MARIA JOÃO SOARES1,

MARIANA MARQUES1, ANA TELMA PEREIRA1, BERTA MAIA1,
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ANA ALLEN GOMES2 & ANTÓNIO MACEDO1

1
Institute of Medical Psychology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal, and 2Department of
Educational Sciences, University of Aveiro, Campus Universitário de Santiago, Aveiro, Portugal

Abstract
Aim. To examine if perfectionism predicts self-reported sleep disturbances over time. Methods. The Hewitt
Flett
Perfectionism Scale was used to assess self-oriented, socially-prescribed (SPP) and other-oriented perfectionism. Sleep
disturbance was evaluated with two items: difficulty in falling asleep and waking up many times during the night. Out of 870
students who participated at baseline, 592 and 305 completed the same measures 1 year (T1) and 2 years later (T2),
respectively. Results. Subjects who reported insomnia at baseline, T1 and T2 (persistent insomnia) had significantly higher
scores of baseline SPP (T1 M 51.5, SD 15.8; T2 M55.0, SD 19.0) than subjects reporting, in all stages of the study,
never/rarely having had sleep problems (T1 M41.9, SD 11.4; T2 M 42.2, SD 12.3, P B0.001 in both cases).
For personal use only.

Regression analyses showed that baseline SPP was the only significant positive predictor of difficulties in falling asleep at T1
and T2 (T1 partial R0.187; T2 partial R0.196, P B0.001) and of difficulties maintaining sleep (T1 partial R0.116;
T2 partial R0.244, P B0.001). Conclusion. SPP was found to be the most reliable predictor of sleep disturbances over
time, which constitutes a new important finding.

Key words: Personality, perfectionism, sleep disturbance, longitudinal study, university students

Introduction (Frost et al. 1990; Hewitt and Flett 1991). These

The harmfulness of perfectionism was acknowl-
edged by several clinicians long ago (Hollender
1965; Burns 1980). Recurrent themes from the
early descriptions of perfectionistic subjects included
their unrealistically high and rigid standards for
performance, fear of failure, excessive self-criticism
and the inability to derive satisfaction from their
achievements. Even though Hamachek (1978) pro-
posed the distinction of two perfectionism forms,
normal and neurotic, in the 1980s, a unidimensional
conceptualization of perfectionism dominated, pre-
senting this trait as dysfunctional and associated with
psychopathology (Pacht 1984). In the early 1990s
this conceptual framing began to change. Two
independent groups with the heuristic intention of
capturing the core facets of perfectionism demon-
strated that this trait would be most correctly
examined as a multidimensional construct with
both intrapersonal and interpersonal dimensions
authors provided perfectionism researchers with two
different instruments that nevertheless share the
same name
the Multidimensional Perfectionism
Scale (MPS).
Hewitt and Flett (H&F, 1991) described their
perfectionism dimensions based on perfectionistic
behaviour/expectations direction (self-directed vs.
directed to others) and source (e.g., intrapersonal
vs. interpersonal). The H&F-MPS distinguishes
three components: Self-Oriented Perfectionism (SOP,
intrapersonal facet involving unrealistic self-imposed
standards and critical self-monitoring); Socially-
Prescribed Perfectionism (SPP, interpersonal dimension
related to the perception that others significant hold
excessively high standards and expectations of per-
fection for oneself); Other-Oriented Perfectionism
(OOP, interpersonal component which involves the
expectation that others should achieve unrealistic
standards). Hewitt and Flett (1991) suggested that
SOP was directed toward avoiding self-criticism,

Correspondence: Maria Helena Azevedo, MD, PhD, Institute of Medical Psychology, Faculty of Medicine, University of Coimbra, Rua
Larga, 3004-504 Coimbra, Portugal. Tel: 351 239 857759. Fax: 351 239 823170. E-mail: mazevedo@fmed.uc.pt

(Received 15 May 2009; accepted 2 July 2009)

ISSN 1562-2975 print/ISSN 1814-1412 online # 2010 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS)
DOI: 10.3109/15622970903304467

whereas SPP was directed toward avoiding disap-
proval by others.
Frost and colleagues (1990), conversely, proposed
that six perfectionism facets should be differentiated
in their instrument (F-MPS): Personal Standards
(PS, reflecting the setting of high personal
demands); Organization (O, emphasizing that per-
fectionists value order and precision); Concern over
Mistakes (CM, indicating the extent to which the
person is concerned with making mistakes); Doubts
about Actions (DA, reflecting the person indecisive-
ness about one’s performance quality). The instru-
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ment presents two additional subscales of an
interpersonal nature which are circumscribed to
the familial environment: Parental Expectations (PE)
and Parental Criticism (PC) (addressing the great
importance that perfectionists attach to evaluations
by their parents). According to Flett and Hewitt
(2002) this more restricted scope is inadequate. The
authors believe that it is important to consider other
people’s role (i.e. peers and teachers) and socio-
cultural factors.
The recognition of perfectionism as a multidimen-
sional phenomenon, with both adaptive and mala-
daptive components, has enhanced the compre-
For personal use only.
hension of normal psychological development. It
has also elucidated the role of perfectionism in the
development of several psychopathological problems
to which it has been linked and the mechanisms
underlying these associations (Shafran and Mansell
2001).
Regarding the association between perfectionism
and sleep problems, in the 1980s some investigators
pointed out that the arousal characterizing insom-
niacs is, in fact, an emotional arousal emerging from
an anxious perfectionistic personality style (Lacks
1987). In spite of these early attempts to understand
the mechanisms involved in the relationship of
perfectionism with sleep disturbances, since then
this topic has received little attention (Lundh et al.
1994; Vincent and Walker 2000). In the study by
Lundh et al. (1994), perfectionism was assessed with
a shortened version of Frost-MPS (Frost et al.
1990). In their normal sample, perfectionism corre-
lated with a composite score on degree of sleeping
problems. In the clinical sample, obtained from a
sleep disorders clinic, the authors found that patients
with persistent insomnia had significantly higher
scores of perfectionism than controls, especially on
the subscales CM and PS. Within the insomnia
group, patients with a concomitant diagnosis of
major depression differed from the non-depressed
insomniacs by having higher scores on the subscale
DA. Lundh et al. (1994) hypothesized that perfec-
tionism (high PS and high CM) may serve as a
predisposing factor for the development of persistent
Perfectionism and sleep: longitudinal study 477
insomnia. Vincent and Walker (2000) used both
MPS instruments in a small sample of 32 adults who
responded to an advertisement placed in a commu-
nity newspaper offering treatment for chronic in-
somnia and 26 healthy controls No significant
associations were found between any of the H&F-
MPS dimensions and insomnia, although insomniac
subjects tended to report more SPP than healthy
controls. Regarding F-MPS, subjects with chronic
insomnia were more likely to report DA, frequent
PC, and CM. However, delayed sleep-onset latency
was only related to the perception of heightened PC.
In a previous study with undergraduate students of
both genders we found an association between sleep
disturbances and perfectionism (Azevedo et al.
2007). Further correlational and categorial analyses
revealed that SPP was the only dimension associated
with sleep disturbance in subjects of both genders.
Males with the highest levels of SPP were approxi-
mately twice more likely to report sleep disturbances
than those with less SPP. Similar results were found
within the female sample. However, a positive small
correlation between SOP and sleep measures was
observed in females.
The literature is sparse on the long-term effects of
maladaptive perfectionism on sleep. To our knowl-
edge only one prospective study examined the
relationship between perfectionism and insomnia
(Jansson-Fröjmark and Linton 2007). In this study
with 1936 subjects from the general population, who
completed perfectionism, psychological distress and
insomnia measures at baseline and 1-year follow-up,
F-MPS dimension CM was significantly associated
with pre-existing and future insomnia.
In the present study, the main objective, following
a longitudinal perspective, was to further investigate
the association between perfectionism and self-
reported sleep disturbances in a non-clinical sample
of undergraduate Portuguese university students of
both genders in order to identify which perfection-
ism dimensions might best predict risk of developing
sleep problems.
Methods
This research was reviewed and approved by the
Medical Ethics Review Committee of the University
Hospital of Coimbra (Macedo et al. 2002).
Procedure
Students were approached and measures were com-
pleted, as described previously, for the study first
stage (Azevedo et al. 2007). Data were collected at
three stages/times separated by intervals of one
academic year (2000/2001, 2001/2002, 2002/2003),
 478 M.H. Azevedo et al.

when exams periods were not taking place. Baseline
was considered the first stage, the first year of the
follow-up was Time 1 (T1) and the second year of
the follow-up was Time 2 (T2). The cooperation
was voluntary, in all stages, and confidentiality was
ensured. Most students returned the questionnaires.
Participation refusal occurred when questionnaires
were not handed.
verify if the former groups were representative of the
whole cohort subjects. Subjects followed up at T1
had higher baseline SOP than subjects who were not
followed up (M 82.5, SD 14.90 vs. M 79.10;
SD 16.79, t 2.820; P 0.005). Apart from this
observation, no other significant differences were
identified between groups.

Measures
Participants
Perfectionism. Hewitt and Flett-MPS (1991) was
Table I presents participants characteristics at each
used to measure Self-oriented perfectionism,
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stage of the study. Mean age (standard deviation)

Socially-prescribed perfectionism and Other-or-
at baseline was 19.59 years (SD 1.61; range 
iented perfectionism. The scale has 45 items, and
17
25), at T1 was 20.34 years (SD 1.41; range
the subject is asked to rate each item on a seven-
18
26) and T2 was 20.88 years (SD 1.08;
point scale ranging from strongly disagree (score 1) to
range 19
26). Of the students assessed at baseline,
strongly agree (score 7). Theoretically the scores may
65 and 48.5% completed the same measures 1 year
range from 45 to 315. A higher score is considered
(T1) and 2 years later (T2), respectively. The
an indicator of higher levels of perfectionism. The
attrition rates might be explained by the fact that
Portuguese version of the MPS has already been
in the third year of the Medicine Course a consider-
found to possess good psychometric properties
able number of modules started to take place at the
(Azevedo et al. 2007). Groups of perfectionism
University Hospital instead of at the Faculty. Classes
were formed based on baseline data scores and using
at the Hospital usually require clinical observations/
as cut-off points 1 SD below the mean (group with
interviews of the/to patients. For this reason, it
For personal use only.

low scores) and 1 SD above the mean (group with

became more difficult for students to have free
high scores). This procedure was performed for the
time at the end or beginning of the classes to
scale total score as well as for each perfectionism
participate in research studies. Subjects who were
followed up at T1 (n 592) and T2 (n 305) were dimension scores (SOP, SPP, and OOP).
compared with the remainder cohort subjects (the
Sleep disturbances. Two items, presented as state-
ones who did not participate at T1, n 278; and at
T2, n 565) on perfectionism dimensions means ments, were used to assess sleep disturbances: (1) I
and sleep variables at baseline. This made possible to have difficulty in falling asleep (difficulties initiating
sleep, DIS) and (2) I wake up many times during the
night (difficulties maintaining sleep, DMS). Each
Table I. Sample characteristics at baseline and follow-up.
item is scored on a six-point scale ranging from 0
Baseline (N870) T1 (n 592) T2 (n 305) (never) to 5 (always). In addition to scores obtained
N (%) n (%) n (%) for DIS and DMS (possible range 0
5), an overall
sleep disturbance score index (SDI) was calculated
Age
17
18 241 (27.7) 10 (1.7)

summing the scores of the individual items (possible
19
20 358 (41.1) 344 (58.1) 128 (42.0) range 0
10). Higher scores indicate greater subjec-
21
26 193 (22.2) 230 (38.9) 174 (57.0) tive sleep disturbance.
Gender Based on these items the following groups were
Males 326 (37.5) 210 (35.5) 99 (32.5) formed:
Females 544 (62.5) 382 (64.5) 206 (67.5)
1. Good sleepers: subjects who referred that
Marital status
Single 861 (99.0) 591 (99.8) 305 (100.0) ‘‘never’’ or ‘‘rarely’’ had DIS/DMS at baseline
Married 4 (.5) 1 (.2)
and at follow-up.
Course 2. Persistent insomnia: subjects who reported
Medicine 706 (81.1) 453 (76.5) 277 (90.8) having ‘‘often’’, ‘‘very often’’ or ‘‘always’’ DIS/
Dentistry 161 (18.5) 136 (23.0) 27 (8.9) DMS at baseline and at follow-up.
Course year 3. Onset insomnia: subjects with no sleep com-
1st 444 (51.0)

plaints at baseline (never/rarely/sometimes) but
2nd 187 (21.5) 365 (61.7)
reporting sleep complaints (DIS/DMS) either
3rd
6th 200 (22.9) 227 (38.3) 305 (100.0)
at T1 (1 year) or T2 (2 years) of the follow-up.
Note: Numbers may vary due to missing values; T1, Time 1; T2, 4. Insomnia remission: subjects who reported
Time 2. sleep complaints at baseline but who remitted

(never/rarely/sometimes responses) either at T1
or T2.
Data analyses and statistics
To investigate if perfectionism groups (previously
defined) diverged in DIS, DMS and SDI at different
stages of the study (baseline, T1 and T2), Student’s
t-test were applied. Odds ratio analyses were addi-
tionally performed to explore the likelihood of a
subject with high scores in total perfectionism or in
particular perfectionism dimensions experiencing
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long-term sleep difficulties, compared with someone
with low perfectionism scores. To examine whether
sleep groups (formerly defined) differed in perfec-
tionism mean scores at T1, the one-way ANOVA
test was applied. The Tamhane’s test and the least
significant difference test were subsequently used to
investigate differences within specific perfectionism
groups. At T2 the non-parametric test Kruskal

Wallis was used to explore if sleep groups diverged
in perfectionism scores. Mann
Whitney tests were
applied to investigate differences between two spe-
cific groups. Finally, correlation analyses were per-
formed followed by linear regressions to evaluate if
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the three perfectionism dimensions (baseline scores)
explained sleep difficulties (DIS, DMS and SDI) at
T1 and T2. According to Cohen (1992), correla-
tions of 0.10 represent small effect, 0.30 medium,
and 0.50 large effect.
Results
Descriptive data
Perfectionism and sleep variables mean scores and
standard deviations at baseline, T1 and T2 are
presented in Table II.
Difficulty initiating sleep (DIS) described as
‘‘often, very often and/or always’’ was reported by
18.4% at baseline, 16.8% at T1 and 18.9% at T2.
Difficulty maintaining sleep (DMS) reported as
Table II. Perfectionism and sleep variables mean scores and standard deviations (SD).
Baseline (N870)
Mean (SD; range)
Perfectionism
SOP 81.41 (15.60; 18
117)
SPP 44.78 (12.28; 15
94)
OOP 44.84 (6.98; 18
63)
Total scale 186.13 (27.48; 97
265)
Sleep
DIS 1.70 (1.60; 0
5)
DMS 1.18 (0.80; 0
5)
SDI 2.89 (1.64; 0
10)
SOP, Self-oriented perfectionism; SPP, Socially-prescribed perfectionism; OOP, Other-oriented perfectionism; DIS, Difficulties initiating
sleep; DMS, Difficulties maintaining sleep; SDI, Sleep disturbance index; SD, Standard deviation; T1, Time 1; T2, Time 2.
Perfectionism and sleep: longitudinal study 479
‘‘often, very often and/or always’’ was mentioned
by 5.2% at baseline, 5.4% at T1 and 6.8% at T2 (see
Table III). Both DIS and/or DMS were experienced
at baseline, T1 and T2 by 23.6, 22.2 and 25.6%,
respectively.
Perfectionism and sleep variables correlations between
the same variables at different follow-up time points
Correlations (Pearson’s Moment Product Correla-
tions) between Perfectionism variables at baseline
and at T1 and T2 revealed large correlation coeffi-
cients (ranging from 0.51 to 0.78) suggesting a good
temporal stability of perfectionism dimensions (Ta-
ble IV). Spearman’s Rank Correlations between
sleep variables at baseline and at T1 and T2 revealed
medium to large coefficients (ranging from 0.40 to
0.62) suggesting a reasonable temporal stability
within sleep variables (Table IV).
Comparisons between perfectionism groups and sleep
variables
The group with higher perfectionism total scores at
baseline revealed significantly higher mean scores in
DMS (M 1.33, SD 0.91) and SDI (baseline)
(M 3.20, SD 1.86) than the group with lower
perfectionism total score (baseline) (DMS, M
1.01, SD 0.82, P 0.018; SDI, M2.60, SD 
1.56, P 0.024).
The former group also revealed significantly
higher mean scores in all sleep variables (DIS,
DMS and SDI) at T2 (2 years after baseline
measurements) comparatively to the group with
lower total perfectionism scores (at baseline) (see
Table V).
With respect to SPP, the group with high scores in
this dimension (baseline) showed significantly more
DIS, DMS and SDI in baseline, T1 and T2 than the
group with low scores in this dimension (Table VI).
T1 (n592) T2 (n 305)
Mean (SD; range) Mean (SD; range)
79.61 (14.89; 35
119) 77.88 (16.07; 26
119)
43.22 (12.12; 15
96) 43.37 (12.38; 18
97)
45.29 (7.32; 16
63) 45.31 (7.16; 24
62)
183.32 (27.18; 103
302) 181.92 (29.01; 87
277)
1.61 (1.04; 0
5) 1. 67 (1.28; 0
5)
1.23 (0.80; 0
4) 1.13 (0.84; 0
5)
2.84 (1.59; 0
9) 2.07 (1.39; 0
6)
 480 M.H. Azevedo et al.
Table III. DIS and DMS frequency at baseline and follow-up.

Baseline (N870) T1 (n592) T2 (n 305)

DIS DMS DIS DMS DIS DMS

N (%) N (%) N (%) N (%) N (%) N (%)

Never 84 (9.7) 150 (17.2) 56 (9.5) 84 (14.2) 33 (10.8) 41 (13.4)

Rarely 328 (37.7) 467 (53.7) 262 (44.3) 331 (55.9) 124 (40.7) 165 (54.1)
Sometimes 298 (34.3 208 (23.9) 175 (29.6) 145 (24.5) 91 (29.8) 78 (25.6)
Often 100 (11.5) 31 (3.6) 61 (10.3) 22 (3.7) 31 (10.2) 15 (4.9)
Very often 45 (5.2) 9 (1.0) 29 (4.9) 10 (1.7) 20 (6.6) 5 (1.6)
Always 15 (1.7) 5 (.6) 8 (1.4)
6 (2.0) 1 (.3)
NK

1 (.2)

NK, Not known; DIS, Difficulties initiating sleep; DMS, Difficulties maintaining sleep; T1, Time 1; T2, Time 2.
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Considering SOP and OOP dimensions, only a
small number of significant results were found. The
group with high SOP values revealed higher mean
scores in DMS in T2 than the group with low SOP
(M 1.47, SD 0.98 vs. M1.09, SD 0.74, P  0.02).
0.033). The group with high OOP revealed less
DMS (M 1.16, SD 0.80) than the group with
low OOP (M 1.39, SD 0.86).
Exploring SPP in detail, subjects with high values
in this dimension at baseline were approximately 3
times more likely to have overall sleep problems
(x2 9.164; P 0.002; OR 2.696 CI 95%, 1.454
For personal use only.
results were only found for SPP scores. The persis-
tent insomnia group showed significantly higher SPP
values (n 23, M 55.0, SD 19.0) than the good
sleepers group (n 74, M42.2, SD 12.28, P 
Correlational and regression analyses
Pearsons’ correlations between perfectionism di-
mensions and sleep variables showed that SOP at
baseline was significantly and positively correlated

with DIS, DMS and SDI at T2 (Table VIII). SPP

to 5.001), 3 times more likely to report DIS (x2  was significantly and positively associated with DIS,
11.438; P 0.001; OR 3.031, CI 95%, 1.626 to DMS and SDI at T1 and T2. OOP was significantly
5.650) and 2 times more likely to refer DMS (x2  and negatively associated with DMS at T1 (1 year
4.386; P0.036; OR 2.101 CI 95%, 1.097 to after baseline). The magnitude of the correlation
4.024) 1 year later (T1) than subjects with low SPP. coefficients which were statistically significant varied
Moreover, subjects with high SPP at baseline were between small and medium sizes (r 0.094 and
approximately 7 times more likely to refer overall 0.298). Medium coefficients were observed between
sleep disturbance (x2 4.59; P0.047; OR 7.22, baseline SPP scores and SDI and DMS at T2 (r $
CI 95%, 1.08 to 48.48) than subjects with low 0.3). Finally, a multiple linear regression performed
SPP 2 years later (T2). using the three perfectionism dimensions as predic-
tors of DIS, DMS and SDI at T1 and T2 (Table VIII)
revealed that these dimensions (perfectionism base-
Perfectionism and sleep status at follow-up
Table IV. Perfectionism and sleep variables correlations at differ-
Significant differences in total perfectionism and SPP
ent follow-up time points.
were found between sleep groups (T1). Post-hoc
multiple comparisons tests (least significant differ- Baseline Baseline T1
ence, LSD, comparison test) revealed that the onset Variable vs. T1 vs. T2 vs. T2
group and persistent insomnia group had signifi- Perfectionism
cantly higher baseline total perfectionism scores Self-oriented 0.689** 0.606** 0.784**
(M 193.4, SD 26.3, P B0.05 and M193.0; Socially-prescribed 0.732** 0.728** 0.789**
SD 30.5, P B0.05, respectively) than the good Other-oriented 0.544** 0.513** 0.613**
Total scale 0.716** 0.658** 0.764**
sleepers group (M 183.5; SD 26.3) (Table VII).
Tamhane’s comparisons tests also revealed that Sleep
DIS 0.569** 0.504** 0.619**
persistent insomnia group had significantly higher DMS 0.427** 0.397** 0.502**
SPP baseline scores (M 51.5; SD 15.8) than the SDI 0.584** 0.493** 0.554**
remission (M 44.2, SD 9.8, P B0.05) or good
sleepers groups (M 41.9; SD 11.4, P B0.01). DIS, Difficulties initiating sleep; DMS, Difficulties maintaining
sleep; SDI, Sleep disturbance index.
At T2 comparisons failed to reveal significant Note: Pearson’s correlations were applied to Perfectionism vari-
differences between sleep groups (results not ables and Spearman’s Rank correlations were used with Sleep
shown), in respect to SOP and OOP. Significant variables; T1, Time 1; T2, Time 2.
 Perfectionism and sleep: longitudinal study 481
Table V. Comparison between baseline perfectionism total score
enduring personality trait. A reasonable temporal
groups in DIS, DMS and SDI at baseline, Time 1 and Time 2.
stability was equally found when exploring correla-
Group with Group with tions between sleep variables at baseline and at T1
low total score high total score and T2; coefficients ranged from medium to large
Mean (SD) Mean (SD)
magnitudes (0.40
0.62). The highest correlation
n 80 n 88 t P
was found with DIS variable (0.50
0.57). Consis-
DIS tent with previous findings (review Sateia et al.
Baseline 1.59 (1.12) 1.88 (1.20) 1.599 0.112 2000) sleep complaints were found to be stable
Time 1 1.58 (1.05) 1.76 (1.29) 1.021 0.309
over time, with 51% of students with sleep distur-
Time 2 1.48 (1.02) 2.04 (1.45) 2.120 0.037
bances at baseline also reporting symptoms at
DMS
follow-up.
Baseline 1.01 (.82) 1.33 (.91) 2.382 0.018
Time 1 1.15 (.78) 1.30 (.91) 1.113 0.267 Students with high levels of SPP at baseline
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Time 2 1.07 (.74) 1.54 (1.04) 2.535 0.013 showed consistently having more DIS, DMS and
SDI SDI than subjects with low levels of SPP through all
Baseline 2.60 (1.56) 3.20 (1.86) 2.274 0.024 assessment times/stages. These students were 3
Time 1 2.72 (1.56) 3.06 (1.91) 1.225 0.222 times more likely to have overall sleep problems or
Time 2 1.76 (1.28) 2.50 (1.41) 2.628 0.010 DIS, 2 times more likely to have DMS 1 year later
DIS, Difficulties initiating sleep; DMS, Difficulties maintaining (T1), and 7 times more likely to report overall sleep
sleep; SDI, Sleep disturbance index; SD, Standard Deviation; t, disturbance 2 years later (T2) than subjects with low
Student’s t-test. SPP. Additionally, students with persistent insomnia
showed higher scores on SPP, at T1 and T2, than
line scores) explained 4% of the total variance of the good sleepers.
SDI [r2 0.040, F(3, 541) 8.505, P B0.001], One of the earliest and most enduring insomnia
3.4% of the total variance of DIS [r2 0.034; F(3, conceptualisations refers to psychophysiological
541) 7.409, P B0.001] and 2.6% of the total arousal (Buysse and Dorsey 2002). From the several
For personal use only.

variance of DMS [r2 0.026, F(3, 542) 5.882,
P 0.001] at T1. At T2 the three perfectionism
variables explained 6.4% of the total variance of the
SDI [r2 0.064, F(3, 277) 7.274, P B0.001],
5.6% of the total variance of DIS [r2 0.056, F(3,
277) 6.516, P B0.001] and 8.1% of the total
variance of DMS [r2 0.081, F(3, 277) 9.150,
P B0.001]. Considering the partial correlations
between perfectionism and sleep variables, baseline
SPP was a significant predictor of DIS, DMS and
SDI at T1 and T2. DMS at T1 (1 year after
baseline) could be predicted (positive association)
by SPP baseline and by OOP (negative association).
reasons for hyperarousal, psychological distress (PD)
and psychiatric disorders are among the most salient
causes of insomnia (Hauri 2002). It is well known
that the aetiology of PD and psychiatric syndromes
involves the interplay of many biological (e.g.,
genetic) and environmental factors (Tandon and
McGuffin 2002; Rijsdijk et al. 2003). Therefore, as
it would be expected in complex transmission
disorders, the pathway between genetic/develop-
mental risk factors and the behavioural phenotypes
Table VI. Comparison between baseline Socially prescribed
perfectionism groups (SPP) in sleep variables at baseline, Time
1 and Time 2.

Low SPP High SPP

Discussion and conclusions Mean (SD) Mean (SD)
n 83 n89 t P
The main finding of this study, reported for the first
time, is that SPP was found to be the most reliable DIS
predictor of self reported sleep disturbances at 1 year Baseline 1.34 (1.01) 2.00 (1.24) 3.813 B0.001
(T1) and 2 years (T2) of the follow-up. This result Time 1 1.39 (.99) 2.00 (1.20) 3.661 B0.001
Time 2 1.60 (1.15) 2.30 (1.31) 2.756 0.007
confirms our cross-sectional previous results which
indicated that SPP was the only dimension consis- DMS
Baseline .92 (.74) 1.49 (.88) 4.688 B0.001
tently associated with sleep disturbance in under-
Time 1 1.13 (.72) 1.43 (.84) 2.489 0.014
graduate students of both genders (Azevedo et al. Time 2 1.02 (.71) 1.62 (1.00) 3.389 0.001
2007). It also highlights the long-term adverse
SDI
effects of SPP on sleep. Baseline 2.25 (1.39) 3.49 (1.97) 4.790 B0.001
Correlations between perfectionism variables at Time 1 2.52 (1.43) 3.43 (1.74) 3.726 B0.001
baseline with these same variables at T1 and T2 Time 2 1.57 (1.11) 2.66 (1.31) 4.294 B0.001
revealed large correlation coefficients particularly DIS, Difficulties initiating sleep; DMS, Difficulties maintaining
evident when considering SPP (0.73
0.79), lending sleep; SDI, Sleep disturbance index; SD, Standard Deviation; t,
support to the notion of SPP as a measure of an Student’s t-test.
 482 M.H. Azevedo et al.
Table VII. Baseline perfectionism scores by sleep groups at Time 1 (1-year follow-up).
Sleep groups
1 2
Good Sleepers Remission
Baseline n 189 n 54
Perfectionism Mean (SD) Mean (SD)
SOP 81.4 (14.6) 84.6 (12.4)
SPP 41.9 (11.4) 44.2 (9.8)
OOP 45.2 (7.0) 46.1 (7.2)
Total scale 183.5 (26.3) 189.8 (22.8)
(1) Comparisons between groups performed with one-way ANOVA.
(2) Tamhane’s test.
World J Biol Psychiatry Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 03/04/15
(3) LSD test; *PB0.05; **P B0.01.
SOP, Self-oriented perfectionism; SPP, Socially-prescribed perfectionism; OOP, Other-oriented perfectionism; SD, standard deviation.
is not straightforward. Instead, it is a long and
devious road with many crossroads and dead-ends.
Some alternatives ways have been proposed to over-
come this complexity and to clarify the underlying
mechanisms by which genetic susceptibility influ-
ence psychopathological conditions. One consists in
using alternative phenotypic measures (e.g., endo-
phenotypes), including personality traits such as
perfectionism. In a near future, we may discover as
For personal use only.
Insel and Collins (2003) have stated about the
aetiology of anorexia nervosa that its genotype is
not linked to a specific disorder but to a perfectio-
nistic, risk-aversive personality style that confers
vulnerability to many syndromes. There is some
evidence of the involvement of genetic factors in
perfectionism (Lilenfeld et al. 2000; Woodside et al.
2002; Tozzi et al. 2004). Moreover, an association
between perfectionism and insomnia has system-
atically been found in the literature (Lundh et al.
1994; Vincent and Walker 2000; Azevedo et al.
2007). Therefore, based in the existing literature, we
believe that perfectionism can be seen as an inter-
mediate phenotype associated with sleep difficulties.
To support the case of perfectionism as an
intermediate phenotype of sleep disturbances, it is
also important to insure a strong temporal stability
of the influence of this trait measure and, also to
assure that it is not predominantly state-related
(Rice and Aldea 2006). Research on depression
and sleep disturbances supports that perfectionism
is a personality trait with both relative stability and
state dependence effects (Zuroff et al. 1999; Cox
and Enns 2003; Rice and Aldea 2006; Maia et al. in
preparation).
Specific personality traits, including perfectionism
have been associated with cognitive arousal and
psychological distress (PD; Kales et al. 1983; Kales
and Kales 1984; Shafran and Mansell 2001). Some
dimensions of perfectionism (e.g., SPP, CM, DA)
have been consistently related to higher levels of PD
3 4
Onset Persistent
n48 n 57
Mean (SD) Mean (SD) P Comparisons (1)
85.5 (14.6) 84.3 (17.2) 0.231
46.2 (12.1) 51.5 (15.8) 0.000** 4 1**,2* (2)
46.1 (6.1) 42.8 (8.0) 0.05
193.4 (27.0) 193.0 (30.5) 0.038* 1 B 3*, 4* (3)
(Stöber and Otto 2006), specifically to depression,
anxiety, eating and OC disorders (Maia et al. in
preparation).
It is worth mentioning that the main reason for
student’s self-referral in the outpatient clinic for
psychological treatment and counselling of Coimbra
University is stress-related problems, namely social
anxiety and psychological distress associated with
evaluative concerns (Pereira 2004). Likewise, the
study of Cabrita et al. (2004), based in a large
sample of Lisbon University students found that
stress-related complaints (anxiety, depression and
insomnia) were the most frequently stated health
problems to justify the use of psychoactive drugs
during the fortnight before the interview. Tranqui-
lizers (BZD; valerian) were taken by 7.2% students
(with valerian accounting for 35.5% of the total
number of medicines consumed) and 1.7% used
antidepressants.
Therefore, it can be argued that the association
between SPP and future insomnia observed in our
study can be a result of PD experienced by students.
It is noteworthy that, in our study, SPP mean values
for the insomnia group and for good sleepers were
similar to the ones found by Vincent and Walker
(2000) in their chronic insomnia and healthy control
group. In addition, our insomnia group SPP mean
values at T1 were equal to the scores of psychiatric
outpatients with a clinical diagnosis of depression
and/or anxiety, and similar, at T2, to the scores of a
mixed sample of outpatients with eating and/or
obsessive
compulsive disorders found in a previous
study of our group (Maia et al. in press).
It is particularly relevant that certain persona-
lity traits correlate with particular cognitive aspects,
which play a central role in the conceptual
models of PD (Beck 1976; Clark 1999) and in the
explanation of complex mechanisms involved in the
interplay between personality, PD and insomnia.
 Perfectionism and sleep: longitudinal study 483

SOP, Self-oriented perfectionism; SPP, Socially-prescribed perfectionism; OOP, Other-oriented perfectionism; r, Pearson moment-product correlation coefficients; Partial R, partial correlation
According to the cognitive model of insomnia,

0.231**
Partial R

0.013

0.000
worriers and ruminators are more likely to react to
life stressors creating cognitive arousal which, in

T2
turn, will affect sleep, leading to insomnia (Perlis
et al. 2005). There is empirical evidence that some

Sleep disturbances index

0.271**
0.133*
perfectionism negative facets (e.g., SPP) are asso-

0.016
r
ciated with worry, rumination and autonomic arou-
sal (Flett et al. 1995, 1998). Worriers have an
Table VIII. Correlation coefficients and partial correlations between baseline Perfectionism and sleep disturbances scores at Time 1 (n 592) and Time 2 (n 305).

0.181**
elevated and intense fear of failure that makes
Partial R

0.015

0.062
them hesitant about making mistakes. In other
words, they need to be absolutely sure that they
are doing the ‘‘right thing’’ before a response can be
T1
World J Biol Psychiatry Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 03/04/15

0.200** made (Tallis et al. 1991). These are characteristics

0.083*
which overlap with those that have been described in
0.053
r

some of the perfectionism negative facets (DA and

CM; SPP) (Frost et al. 1993; Bieling et al. 2004).
According to Flett et al. (1991) and Frost et al.
(1990) the fact that perfectionists tend to anticipate
0.244**
Partial R

0.042

0.003

stress (worrying about future failures) might be one

of the possible explanations for the association
T2

between SPP and sleep disturbance. Another im-

0.173**
0.298**
Difficulties maintaining sleep

portant mechanism that can explain the relationship

0.094* 0.004

between perfectionism and psychological distress is

Sleep disturbances

the subject coping style. There is a large amount of

literature giving support to the association between
0.116**
Partial R
For personal use only.

0.031

SPP and negative coping responses and negative

cognitive appraisals. Flett et al. (1998) reflect about
rumination as a coping response of perfectionists
which can perpetuate stress in their lives (e.g.,
T1

leading to sleep difficulties).

0.152**
0.097*

Some studies of relevance in the present context

0.065
r

have investigated the association between perfection-

ism and physical health/somatic complaints, includ-
ing sleep problems. Saboonchi and Lundh (2003)
found that SOP and SPP were positively correlated
0.196**
Partial R

0.048

0.049

with somatic complaints such as daytime sleepiness,

headaches, tension, and insomnia. In the study of
T2

Molnar et al. (2006), SPP was associated with

0.141**
0.252**

coefficients; *pB0.05; **p B0.01; T1, Time 1; T2, Time 2.

poorer physical health. This relationship was par-

Difficulties initiating sleep

0.049

tially mediated by low positive affect and high

r

negative affect. Research has demonstrated that

socially prescribed perfectionists tend to rely on
0.187**
Partial R

emotion-focused coping and avoidance-oriented

0.047

0.023

coping, tend to have a negative self-perception of

problem-solving orientation, engage in self-blame,
show a lack of constructive thinking, and deal with
T1

stressful situations in ways that indicate a sense of

0.189**
0.030

0.053

helplessness or hopelessness (Flett et al. 1994, 1996;

r

Hewitt et al. 1994, 1995; Dunkley et al. 2000).

Taken together, these findings suggest that mala-
daptive coping may further contribute to explain the
link between SPP and health complaints.
Perfectionism

In conclusion, a constellation of factors inclu-

ding a negative cognitive style (e.g., proneness to
Baseline

rumination) associated with autonomic arousal and

OOP
SOP
SPP

anxiety (e.g., worry) has been consistently found in

 484 M.H. Azevedo et al.
insomniacs (see Harvey 2002). To our knowledge
there is only one prospective study where these
pathways were analysed. Results showed an associa-
tion between perfectionism, PD and insomnia
(Jansson-Fröjmark and Linton 2007). However,
when emotional distress was accounted for, none
of the perfectionism subscales (CM and PS) con-
tributed significantly to explain pre-existing and
future insomnia.
Future work should examine the mechanisms
linking SPP to insomnia/sleep disturbances, specifi-
cally exploring the role of psychological distress,
World J Biol Psychiatry Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 03/04/15
worry and rumination.
Acknowledgements
The data for this report were drawn from a research
on Perfectionism and Obsessive
Compulsive Spec-
trum Disorders, funded by Fundação para a Ciência
e Tecnologia (FCT
no. 37569/PSI). The co-
operation of Professors and Students is gratefully
acknowledged.
Statement of interest
For personal use only.
None to declare.
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