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The Relationship between Perfectionism and Anorexia Nervosa

By: Jennifer Kim

April 27, 2011

(Helm, 2009)

 

Introduction

Everyone wishes they could look different, excel at different things, or fix things about his or herself.† These thoughts are common but can be harmful when an obsession with changing yourself develops and starts to control your thoughts, life, and eating habits.† The strife for perfectionism often times goes hand in hand with the development of anorexia nervosa.† Many of those that are diagnosed with anorexia nervosa are often times perfectionists or overachievers that excel in a variety of aspects, listen to authority figures, and focus on pleasing others.† Forcing themselves to lose weight acts as a source of control for these individuals and also makes them feel successful.† In a clinical sample population of women with anorexia nervosa, there has been a significantly high level of perfectionism observed.† Anorexia nervosa has been common in individuals who want to control over eating and weight.† In perfectionism a key component is control.† Through an Australian twin registry, Wade published that anorexia nervosa subjects showed increased concerns about making mistakes, doubts about actions, and personal standards.† Therefore it has been stated that when high personal standards are accompanied by psychological vulnerabilities, problems such as eating disorders can develop.† This paper will further study the relationship between anorexia nervosa and perfectionism and the strength of the correlation between the two (Yates, 2010).†

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What is Anorexia Nervosa?

Anorexia nervosa is a serious eating disorder and a psychological disorder that is characterized by excessive weight loss and self-starvation.† The term anorexia literally means ďloss of appetite.Ē† A person is diagnosed with anorexia nervosa when that individualís weight is at least fifteen percent less than his or her normal body weight, depending on height and age.† People diagnosed with anorexia nervosa have fears of becoming obese and have a self-perception that differs greatly from reality.† They view themselves as fat even when they are slim; therefore, they correct this flaw by limiting their food intake and exercising excessively.† Those that are most likely to become anorexic tend to be high achievers that perform well in a variety of aspects.† Commonly, people stop eating to feel more in control or to rebel against certain authority figures present in their lives.† Anorexia nervosa can develop at any time.† However, it is more common in females than males and the risk is higher for those that participate in acting, dancing, modeling, or sports in which appearance and weight are important.† Also involved with the development of anorexia nervosa is low self-esteem, anxiety, anger, loneliness, feelings of inadequacy, troubled relationships, and pressure from peers, society, and media.† Genetics has also been to have an impact in which changes in certain hormones that are responsible for a personís mood, thinking, and appetite help anorexia nervosa develop.† It has also been noted that anorexia nervosa tends to run in families and could possibly be inheritable (Anorexia Nervosa, Cleveland Clinic).

Symptoms of Anorexia Nervosa

Some common symptoms of anorexia nervosa include

         Rapid weight loss during a short period of time

         Fear of gaining weight and feeling fat

         Continually dieting even when weight is low

         Unusual interest in nutritional information

         Strange eating habits

         Loss or irregular menstrual periods in females

         Use of laxatives, diuretics, or diet pills, compulsive weight loss,

         Being self-critical

         Depression, irritability, or anxiety

         Striving for perfection

(Anorexia Nervosa, Cleveland Clinic)

What is Perfectionism?

Perfectionism is a personality trait that is characterized by striving for extremely high standards, determining self-worth based on ability to achieve high standards, and continuing to strive for certain standards despite the negative consequences.† Perfectionists are very critical of their own performance and have the tendency to need the approval of those around them.† Perfectionists are driven by failure and not by the goals they want to achieve.† Also, individuals with high levels of perfectionism are more likely to have negative reactions to their own mistakes and view their mistakes as failures.† This characteristic of perfectionism was associated with anorexia nervosa and was the only aspect of perfectionism that was not linked to any other psychological disorders.† Most patients stated that their perfectionistic characteristic was present before their case of anorexia nervosa developed (Journal of Psychiatry, 2003).†

 

The Two Faces of Perfectionism

Perfectionism is the strife for flawlessness.† It is a characteristic that has negative and positive qualities and is portrayed in two forms:† healthy or destructive.† Those who display a more healthy form of perfectionism are not likely to have their confidence threatened by disappointment.† In contrast, individuals that display the negative aspect of perfectionism have more strict standards of performance and are more likely to feel threatened when faced with failure.† An example of a negative aspect of perfectionism in a very critical form is anorexia nervosa.† Individuals suffering from this eating disorder and perfectionism are more likely to create strict rules for their eating habits, weight, and appearance.† Consequences to this include poor nutrition, lower energy levels, and lowered interest in self-exploration.† In addition, the poor nutrition can worsen concentration levels and motivation.††† Perfectionism can be addressed in which individuals learn to recognize his or her needs, wants, and limits which will allow for a more flexible lifestyle for a negative perfectionist (Zucker, 2002).

 

 

 

Anorexia Nervosa and Perfectionism Studied

Dr. Katherine Halmi, member of the Eating Disorders Program of New York Presbyterian Hospital in Manhattan, and her group of international researchers closely examined the relationship between anorexia and perfectionism in 322 women from the United States and Europe.† It was concluded that there is a direct relationship between anorexia and perfectionism and the extent of perfectionism was directly associated with the severity of each individualís case of anorexia nervosa.† Dr. Suzanne Sunday, an assistant professor of psychiatry at New York Presbyterian, states that the observed relationship between perfectionism and anorexia nervosa could help researchers establish if there is a genetic trait that influences the likeliness for a person to develop an eating disorder.† To pursue this study, researchers enlisted patients who were suffering from anorexia nervosa and had relatives who had also suffered from an eating disorder; both of the individuals were included in the study.† These participants were required to respond to a variety of questions focused on eating disorders, perfectionism, and motivation to change.† Results allowed Dr. Michael Strober, director of the Eating Disorders Program at UCLA School of Medicine, to conclude that perfectionism is a predisposing personality trait because of how commonly it is found in the backgrounds of those with anorexia nervosa which allows researchers to suspect that this personality trait could be a marker of genetic risk factors (Livni, 2009).†

 

ENVIRONMENTAL: I CAN NEVER BE SKINNY ENOUGH

Anorexia nervosa is an emotional disorder that establishes itself through the body.† In the United States, it has affected about 8 million Americans, and 7 million of them are women.† Anorexia nervosa is commonly characterized by starvation, an absence of menstrual cycles, and compulsive exercising.† Those suffering from this eating disorder become preoccupied by food and often times participate in food rituals such as cutting up their servings in tiny portions.† Due to the obsession with maintaining or losing weight after dropping below an acceptable level depending on the individualís height and age, researchers have stated that anorexics have a distorted perception of their body.† Anorexics have the mindset that they can never be skinny enough.†

††††††††††† Dr. Steven Hendlin, a clinical psychologist in Irvine, California, states that he views anorexia as one of the many manifestations of having a perfectionistic personality.† He classifies a perfectionist as a person who constantly thinks that anything short of perfection in his or her performance is intolerable.† In terms of anorexia nervosa, this means that individuals feel that they are not living up to Americaís standards of beauty.† In contrast to the want to excel, perfectionism is motivated by fear and failure.† One patient that wrote for the National Association of Anorexia Nervosa and Associated Disorders, Sara Rosin, described that females suffering from anorexia nervosa believe that they ďshould be everything you possibly can be! Oh Ė and donít forget to be the best at it all!Ē† The pressure of society allows for individuals to strive to overachieve and for perfectionism (Livni, 2009).†

GENETICS

††††††††††† Dr. Steven Hendlin believes that perfectionism is caused by nurture, how a child was raised, and the authority figures that are present in a childís life.† He states that those suffering from anorexia nervosa learned as children that they will not be loved unless they are perfect.† However, many researchers such as Dr. Walter Kaye believe that life experience is only one of the numerous factors that will influence whether a person will develop an eating disorder.† This belief has caused Kaye and a group of researchers to hypothesize that anorexia nervosa may be connected with a family of genes that includes serotonin which is a neurotransmitter connected to mood.† Therefore, finding a genetic marker for anorexia nervosa so that a drug could treat the eating disorder could be a better treatment but for now treatment includes hospitalization and therapy (Livni, 2009).†

Perfectionism in Anorexia Nervosa studied by the University of Toronto

Anorexia nervosa is a severe psychiatric disorder that has high rates of recurrence.† Perfectionism is known to be a common risk factor in the development of anorexia nervosa and is usually present after remission.† In one experiment performed by Srinivasagam three types of patients were compared:† individuals with restricting anorexia nervosa, weight-restored anorexia nervosa patients, and healthy controls.† Two scales were used in order to evaluate these patients:† The Multidimensional Perfectionism Scale (MPS) measures five core dimensions of perfectionism and produces a total perfectionism score.† The Eating Disorder Inventory Perfectionism (EDI) subscale measures personal expectations in terms of achievement.† The two groups that suffered from anorexia nervosa scored higher than the control group on all the subscales of the Multidimensional Perfectionism Scale and on the Perfectionism subscale of the Eating Disorder Inventory.† In addition it has been reported that the women who had recovered from anorexia nervosa had higher scores on both MPS total perfectionism and EDI perfectionism scales than the control.

What is this Experiment?

One of the most common implicated risk factors in the development of anorexia nervosa is perfectionism.† Perfectionism is known to persist even after anorexia nervosa remission.† This study consisted of observing patients at admission, discharge, and a 6-24 month follow up in order to compare those that were currently suffering from anorexia nervosa and those that had restored their weight in terms of perfectionism.† It allowed researchers to study the relationship between perfectionism and the clinical status of patients diagnosed with anorexia nervosa.†

The Process

This experiment took place at the Toronto General Hospital.† To be eligible, participants had to have at least 4 weeks of treatment and had met the criteria for anorexia nervosa created by the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders.† The patients were successively discharged from treatment between November 1, 1997 and July 31, 2000.† The control group consisted of healthy women who had previously served as controls for a family study created by Lilenfeld in 1998.† Within two weeks of inpatient admission the participants completed the EDI and the Eating Disorder Examination (EDE).† The EDI was directed to patients who had achieved a body mass index of at least 20 kg/m^2 with completion to the treatment program.† All the patients that were eligible were included in a 6-24 month follow up assessment that was post treatment in which they would complete the EDE, EDI, and MPS.† EDE was used to assess clinical status.† The average follow up duration was 15.7 months with a standard deviation of 6.2 months.†

The Scales

In order to compare EDI Perfectionism scores among the patients, healthy controls, and the eating disorder reference samples, one sample t tests were performed.† Researchers also wanted to compare the EDI scores between the good and poor outcome groups and between those that did not complete the treatment program and those that did; therefore, they did a separate sample t test for these comparisons also.† To observe the changes that took place in the EDI Perfectionism scores between the good and poor outcome groups at admission, discharge, and follow up they used the analysis of variance (ANOVA).† ANOVA was also used to analyze MPS total perfectionism comparisons.† To compare the subscales of MPS between the groups one way multivariate analysis of variance was used and ANOVA was conducted on each subscale at the .01 level.† The results are displayed in the tables under the data & results section.†

 

The Data & Results

The sampled population included 71 women and 2 men and the mean age was 27 years.† The observed mean duration of anorexia nervosa was 62.4 months with a mean admission body mass index of 14.8 kg/m^2.† The average duration of treatment was 12.1 weeks.† The average weight gained during treatment was 11.3 kg and had a mean BMI of 19.1 kg/m^2 by the end of the treatment program.† At admission, 36 patients of the participants met criteria for anorexia nervosa restricting subtype and 37 met criteria for anorexia nervosa binge eating/purging subtype.† 55 of the patients then completed the pretreatment assessments, 27 completed the post treatment assessments, and 63 participated in the follow up interviews.† Those that participated in the pretreatment assessment had reported significantly higher mean perfectionism scores than the control group.† Those at post treatment for weight-restored participants did not show a significant difference in comparison to the controls.† However the participants in the follow up good outcome group had a significantly lower Perfectionism score than the poor outcome group and the poor outcome group had higher scores than the healthy controls.† Only twenty three of the patients participated in the EDI all three times and of these patients 13 had a good outcome and 10 had poor outcomes.† The comparison between the non-completers and completers showed that those who had finished the treatment were more likely to have a good outcome and lower pretreatment EDI Perfectionism scores.† Analysis of the three groups on the five subscales of MPS revealed that the poor outcome group had higher scores than the control group on all subscales.† The good outcome group also had higher scores than the control group on all subscales except the Parental Expectations subscale.† The results of this study allowed researchers to conclude that individuals suffering from anorexia nervosa are more perfectionistic than the healthy controls and that perfectionism scores remain significantly high even for those in remission.† The observed association between higher degrees of perfectionism at pretreatment and poorer response to treatment shows that patients who are very perfectionistic are less likely to complete the treatment program.† The severity of the eating disorder is a reflection of levels of perfectionism.† Another theory about perfectionism is that it also prevents patients from giving up their eating disorder because of their fear of failure and desire for achievement.† It is possible that those who have very high levels of perfectionism may have a more difficult time to engage in group therapy because it requires revealing themselves as imperfect.†

 

This table displays the comparison between participants with anorexia nervosa at pretreatment, post treatment, and follow up compared with healthy controls in terms of EDI Perfection.†

Assessment

Participants

Healthy Controls

Probability

Eating Disorder Reference Sample

Probability

Pretreatment (n=55)

9.5 (5.0)

6.2 (3.9)

<.001

8.9 (4.9)

.38

Post treatment (n=27)

7.4 (4.2)

6.2 (3.9)

.16

8.9 (4.9)

.07

Good Outcome (n=21)

6.5 (3.5)

6.2 (3.9)

.68

8.9 (4.9)

.005

Poor Outcome (n=28)

9.9 (5.7)

6.2 (3.9)

.002

8.9 (4.9)

.37

Mean Perfectionism (SD)

MPS & status at follow up for participants and controls

MPS is the Multidimensional Perfectionism Scale; ANOVA= analysis of variance.†

 

Good Outcome (A)

Poor Outcome (B)

Healthy Controls (C)

One-Way ANOVA F(df)

Probability

Group Comparisons

Total Perfectionism

94.2 (15.1)

105.7 (20.8)

58.4 (12.0)

85.48 (2, 88)

<.001

A, B > C

Concern Over Mistakes

31.7 (6.9)

34.8 (7.8)

15.0 (4.3)

105.62 (2, 88)

<.001

A, B> C

Personal Standards

26.0 (5.0)

27.2 (4.8)

19.7 (5.2)

22.03 (2, 88)

<.001

A, B>C

Parental Expectations

13.5 (6.0)

16.1 (6.0)

11.1 (3.9)

8.04 (2, 88)

.001

B>C

Parental Criticism

10.6 (3.8)

13.0 (5.1)

5.8 (2.6)

32.64 (2, 88)

<.001

A, B>C

Doubting of Actions

12.5 (4.3)

14.5 (3.7)

6.7 (2.1)

55.33 (2, 88)

<.001

A, B>C

 

A Proper Population Representation

Although this experiment had an excellent way of measuring levels of perfectionism and criteria for anorexia nervosa it could be unreliable because of the small number of people who completed the EDI all three times.† This could mean that the sample population used is not a proper representation of the whole population.† These findings, if replicated in a larger more representative sample can create a more thorough understanding of the relationship between perfectionism and anorexia nervosa (Sutandar-Pinnock, 2009).

 

Conclusions

Anorexia nervosa is a severe disorder that is becoming increasingly prevalent in todayís society.† The effects of genetics, family, peers, society, and media have created an image that many girls feel inclined to become.† In order to prevent the increase of cases in anorexia nervosa, researchers have studied what traits are correlated with the disorder such as perfectionism.† This pressure to be perfect is also created by society and can overwhelm individuals to the point of self-destruction in the form of eating disorders.† To prevent this type of self-worsen it is important to further investigate the correlation between anorexia nervosa and perfectionism.† By being able to learn more about the impact of perfectionism in developing anorexia nervosa, it is possible that eating disorders can be targeted before they develop.† Therefore, it is necessary that researchers perform more experiments with an appropriate representation of the population to prevent the prevalence of anorexia nervosa from increasing.†

 

 

 

 

 

 

 

 

 

 

References

Journal of Psychiatry. (2003, February 5). Perfectionism Linked to Anorexia, Bulimia in Women. WebMD - Better information. Better health.. Retrieved April 27, 2011, from http://www.webmd.com/news/20030205/perfectionism-linked-to-eating-disorders

Anorexia Nervosa. (2009, January 5). Cleveland Clinic. Retrieved April 27, 2011, from http://my.clevelandclinic.org/disorders/anorexia_nervosa/hic_anorexia_nervosa.aspx

Helm, D. (2009, September 28). Is this the perfect girl?. Flickr. Retrieved April 27, 2011, from www.flickr.com/photos/daniellehelm/3962891383/)

Livni, E. (2009, November 17). Perfectionism Linked to Anorexia, Bulimia in Women. WebMD - Better information. Better health.. Retrieved April 27, 2011, from http://www.webmd.com/news/20030205/perfectionism-linked-to-eating-disorders

Sutandar-Pinnock, K. (2009, October 3). Perfectionism in anorexia nervosa: A 6‚Äď24‚Äźmonth follow‚Äźup study - Sutandar‚ÄźPinnock - 2003 - International Journal of Eating Disorders - Wiley Online Library. Wiley Online Library. Retrieved April 27, 2011, from http://onlinelibrary.wiley.com/doi/10.1002/eat.10127/pdf

Yates, W. R. (2010, December 7). Temperament of perfectionism in anorexia nervosa. KevinMD.com | Social media’s leading physician voice. Retrieved April 27, 2011, from http://www.kevinmd.com/blog/2010/12/temperament-perfectionism-anorexia-nervosa.html

Zucker, N. (2002, August 14). Perfectionism and Eating Disorders - Anorexia and Bulimia. Bulimia.com - Eating Disorders Resource for Recovery and Education. Retrieved April 27, 2011, from http://www.bulimia.com/client/client_pages/newsletteredt8.cfm

 

 

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