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“Thinspiration”: The Link between Anorexia Nervosa and Perfectionism
12 September 2007
“Striving for excellence motivates you; striving for perfection is demoralizing.”
–Dr. Harriet Braiker
In a society so enthralled with celebrity ‘hotspots,’ the newest fashion trends, and the glamorous Hollywood lifestyle, physical beauty is transformed into an obtainable necessity. With advertisements promoting rapid weight loss through the use of a pill or bone-thin celebrities posing in magazines, girls are being exposed to the distorted ideas of beauty at a younger age. Since thinness is being portrayed as the beauty of today’s society, girls strive to obtain the perfect, ideal body. At a certain point, this attempt can transform into a lifestyle and result in the development of anorexia nervosa, a serious eating disorder and health problem. Although there is no known etiology for anorexia, various studies have been performed highlighting the various risk factors and symptoms. However, multiple studies have shown that girls with certain personality traits may be more susceptible to developing anorexia. Perfectionism is defined as a personality characteristic involving a tendency to place excessive emphasis on precision and organization, the setting of and striving for unrealistic personal standards, critical self-evaluation if these standards are not reached, excessive concern over mistakes, and doubts about the quality of personal achievements (Castro-Fornieles et al. 562) . Recent studies have revealed a significant relationship between perfectionism and anorexia nervosa. By understanding and interpreting this relationship, it may be possible to detect and prevent anorexia nervosa in a person before the disease becomes too severe. Thus, it is imperative to study this relationship in depth and truly comprehend its dangers.
Background of Anorexia Nervosa
Anorexia nervosa is a serious eating disorder distinguished by an intentional weight loss of fifteen percent or more of normal body weight. Anorexia nervosa is characterized into three clinical subtypes based on the individual’s interaction towards food: restricting, binging, and binge eating and purging. Anorexia is associated with an obsession with food, body image, and weight loss. Anorexics tend to lose a rapid amount of weight, lose hair, demonstrate depressive behavior, maintain eccentric eating rituals, avoid social gatherings where food is present, abuse diuretics, lose interest in sex, grow soft hair on body and face, maintain low body temperatures and blood pressure, and cease
their menstrual cycles (http://www.medicinenet.com/anorexia_nervosa/article.htm).While the causes are still unknown, researchers are investigating the various social, psychological, biological, and environmental factors that may have a role in the etiology of this disease. Although at the present time scientists have been unable to isolate a gene responsible for anorexia, significant evident suggests such a gene does exist. In addition, various environmental factors - such as the rewarding of thinness in the media - seem to be detrimental in the development of anorexia. Regardless of its cause, anorexia has developed into a serious matter accounting for the leading mortality rate among psychiatric conditions (Medicine Net). However, early diagnosis and treatment has been proved to mitigate the overall prognosis of patients of Anorexia (http://www.emedicine.com/emerg/topic34.htm). Yet, in order to fully recover, a patient must be completely willing to participate in a treatment plan. The following list outlines the various treatment methods that have been exercised on anorexia patients (http://psychcentral.com/disorders/sx2t.htm):
Unfortunately, nearly 20% of people with anorexia nervosa remain chronically ill forever (Medicine Net). With no known cure or treatment, anorexia nervosa has evolved into a popular subject of study for the twenty-first century.
Anorexia Nervosa and Perfectionism:
A Dangerous Combination
Numerous studies have linked perfectionism to anorexia nervosa.
With this known, it may be possible to diagnose individuals prior to or in the
early stages of anorexia thus elevating the survival rate and enhancing the
treatment mechanisms. However, if the two are allowed to coexist for an
extended period of time, there can be very severe outcomes. One might wonder
why such a combination could be so dangerous or detrimental to one’s health.
First, the notion of perfectionism has to be completely understood.
Perfectionism is a pursuit of unrealistic goals stemming from the belief that a
state of flawlessness exists. It may act in concord with low self-esteem or
body dissatisfaction. Perfectionists are self-critical and dependent upon
their success for happiness. When perfectionists perceive the unrealistic
standards for physical attractiveness and beauty in society, they transform
them into unrealistic goals. So when an individual copes with perfectionism,
he/she is more likely to desire the “perfect” body. In order to achieve such
an unrealistic goal, individuals can develop an eating disorder. This
relationship can evolve into such an unhealthy manner that its victims
associate the intake of any food as failure or hindrance to the main goal. In
a way, anorexia feeds on the notion of perfectionism.
Various studies published in scientific journals have identified the trend of coexistence of perfectionism and anorexia. The five studies below all address the notion of perfectionism as a common trait among patients with anorexia nervosa. Abstracted from diverse journals, each article gives different insight and perspective regarding the subject matter.
In 2000, Halmi et al. performed a study investigating the role of perfectionism as a phenotypic trait in anorexia nervosa and its relevance due to clinical subtype, i.e. anorexics characterized as restricting, purging, or binge eating and purging. The subjects included 322 women with a history of anorexia nervosa, all grouped by one of the three clinical subtypes. The measures used to assess the women were the following:
The two measures assessing perfectionism – the Multidimensional Perfectionism Scale and the Eating Disorder Inventory-2 – were correlated. The data provided evidence that subjects were more perfetionistic while their eating disorders were the most severe. In addition, these subjects also exhibited increased eating preoccupations and rituals.
However, the study presented some complications that could have created discrepancies. First of all, the comparison subjects were only from one geographical area. Results, although unlikely, could represent an area’s environmental viewpoints rather than proof that perfectionism and anorexia are linked. In addition, descriptive studies such as questionnaires and interviews are always subject to the bias of the observer. Since there is no direct control of the variables, it is hard to determine causality, and each case is unique to the individual. Nevertheless, the study appeared to present valid information regarding a definite connection between perfectionism and anorexia.
Two years later, another study – conducted by Cockell et al. – was published assessing trait and self-presentational dimensions of perfectionism among women with anorexia nervosa. This study differed from the previous one in that it introduced “self-oriented” perfectionism. This “self-oriented” perfectionism was defined as attempting to create an image of flawlessness to others. Such a concept disregards the thoughts of perfectionism as a completely environmentally induced effect. The study proposed that anorexic women were more likely to yearn to present a picture of perfection by hiding emotions and concealing flaws. The study assessed levels of perfectionistic self-presentation in anorexic women. Furthermore, a group of patients with depressive disorders were included to determine the specificity of the case.
Three groups partook in this investigation. The first group consisted of 21 women with anorexia nervosa. A birth cohort was created with participants of a similar age, education, age of symptom onset, length of disorder, and Body Mass Index (BMI). The second group, the normal control group, consisted of 21 women from the hospital, restaurant, or recreation center in the same city. Their ages and education levels matched those of the anorexic group. The third group, the psychiatric control group, was composed of 17 participants exemplifying moderate levels of difficulty in social, occupational, or school functioning. These participants denoted a variety of affective, mood disorders and were recruited from in- and outpatient programs at the hospital. The measures used to assess all three groups were the following:
The full EDE was given to women with anorexia nervosa, yet all the groups participated in the diagnostic items. Interviews were performed, and questionnaires including the MPS, PSPS, BDI, and RSES were completed. Analysis showed that women with anorexia nervosa demonstrated higher levels of depression, low self-esteem, and lower functioning as compared to the psychiatric control women. The control group exhibited the lowest level of psychiatric distress. In addition, multiple comparisons displayed that women with anorexia reported higher scores than psychiatric and normal control women for trait and self-presentational perfectionism. This study demonstrates the strong need of anorexics to present a picture of perfection. These findings indicate that anorexia and self-oriented perfectionism are indeed related. Clearly, patients of anorexia have a personality orientation of perfectionism.
As with all studies, limitations can taint the results. One setback the researcher mentions was the use of unstructured clinical interviews rather than structured interviews. Furthermore, a cross-sectional design was utilized. Such a design prevents the researchers from drawing conclusions about the role of perfectionism in the etiology of anorexia. Regardless, valuable information regarding the high levels of self-oriented perfectionism in patients of anorexia was assessed in the study.
A year later, in 2003, Bulik et al. investigated the relationship between eating disorders and components of perfectionism in twins. The subjects were gathered from the Virginia Twin Registry and were characterized as female-female twin pairs born from 1934 to 1974. Four interviews were conducted, and the MPS questionnaire was administered. Among the seven psychiatric syndromes tested (anorexia nervosa, bulimia nervosa, major depression, alcohol abuse, anxiety disorder, panic disorder, miscellaneous phobia), the “concern over mistakes” section was uniquely characteristic of individuals with anorexia nervosa. Furthermore, multivariable regression models asserted that the most dominant facets of perfectionism measured in anorexics were the sections highlighting “concern over mistakes” and “doubts about actions.” Thus, these aspects of perfectionism appear to be a prominent characteristic of anorexia. The researchers asserted the major limitation of the investigation was that it was not prospective, and thus, could not be used to investigate the concept of perfectionism as a cause or consequence of an eating disorder.
In February of 2007, a study conducted by Pieters et al. was published examining action monitoring and perfectionism in anorexia nervosa patients. Participating in the study were seventeen restrictive anorexia patients and nineteen controls – all matched for sex, age, and educational background. Patients were hospitalized in an eating disorder facility for one year. Patients did not take medications at least 24 hours prior to testing. After weighing and measuring the participants on the testing days, self-report questionnaires – Symptom Checklist (SC) and Beck Depression Inventory (BDI) – were administered . The psychological and clinical factors directly related to eating disorders were evaluated using the eating disorder evaluation scale (EDES) and the eating disorder inventory (EDI). The MPS supplied the information regarding the perfectionistic personality of the patient.
In order to assess reaction times and error rates of the patients, the flankers task was utilized. This test required participants to respond with their right or left finger to a central letter (H or S) in a congruent (HHHHH and SSSSS) or incongruent (HHSHH and SSHSS) letter string. Feedback was given indicating whether the previous response was correct, incorrect, or too late. The experiment took about 40 minutes, and conclusions were based upon the participant’s speed, accuracy, reaction time, and error rate.
The following two figures display the results of the tests:
Figure 1. This graph exhibits the performance adjustments made by each group following erroneous responses. The reaction times for the anorexia nervosa group and the control group are given for the responses following correct answers (post-correct) and the responses following incorrect answers (post-error). The error bars represent the standard deviations.
Figure 2. These scatter plots demonstrate the relationship between the ERN amplitude and the error rate in the anorexia nervosa group and the control group. Larger ERNs correspond to more negative values.
After analyzing their data collection, the researchers noted that the restrictive anorexic patients scored higher than the controls on the MPS scale. In addition, the patients demonstrated fewer errors in the flankers task. This could be due to a more controlled response style utilized by the anorexia patients. Furthermore, the anorexia nervosa group appeared to provide less erroneous responses following an incorrect response, again providing credibility to their more perfectionist response style compared to the impulsive instincts of the control group. The study revealed the perfectionistic behavior of many patients of anorexia nervosa.
The researchers noted a possible limitation was the fact that some of the anorexic patients were on medications such as benzodiazepines for sleep and selective serotonin reuptake inhibitors (SSRIs). Although the patients were rejected these medications 24 hours prior to testing, the possible influences of medication should be acknowledged. Another limitation was the lack of data supplying the exact number of corrections. Correcting was not an option in these tests. The first answer was the only recorded piece of information. Regardless, valuable information was revealed in this recent investigation.
A few months later, a study by Castro-Fornieles et al. was published exploring the self-oriented perfectionism in eating disorders as compared to other psychiatric disorders as well as subjects from the general population. The female subjects used were distributed as the following: 75 anorexia nervosa patients, 33 bulimia nervosa patients, 86 psychiatric patients, and 213 healthy participants. The measures taken were the following:
· Child and Adolescent Perfectionism Scale (CAPS): This self-report questionnaire evaluates levels of perfectionism while dividing it into two branches – “self-oriented” and “socially-prescribed”.
· Eating Disorder Inventory-2 (EDI-2)
The patients exhibited a significant difference among the other two groups on the EDI-2 scale as well as the EAT. In addition, they demonstrated greater levels of perfectionism. Self-oriented perfectionism was more common in patients, yet socially prescribed perfectionism was present as well. By entering the scores obtained from the CAPS into a logistic regression analysis, self-oriented perfectionism was determined to be an independent predictor of an eating disorder. Thus, this data proved the influential existence of self-oriented perfectionism in anorexia nervosa.
As with all studies, there were various limitations that must be considered. First of all, many of the scales and questionnaires were based upon the patient’s sincerity and honesty. In addition, the cross-sectional nature of the study disposed of any possibility of providing a prognosis of the disease. However, the recent study has given much insight about anorexia nervosa and provides science with a definite relationship between self-oriented perfectionism and anorexia nervosa.
Anorexia nervosa is a very serious health problem that is only becoming progressively worse in today’s society. Girls are deteriorating, literally, right before our eyes. An early diagnosis destines a better chance of recovery. Since these studies have revealed that anorexia nervosa is definitely intertwined with perfectionism, it may be easier to recognize and treat the disease in its early phase. Perfectionism is a fairly common personality trait, and its relationship with anorexia nervosa could essentially mean that many people could be susceptible to anorexia nervosa. Thus, it becomes crucial to fully comprehend anorexia nervosa and its health severities. By thoroughly understanding the disease and its complexities, one can better assess it. Knowing that individuals with perfectionistic character traits are definitely more vulnerable to the development of such a disease gives scientists reason to continue conducting research and performing experiments. Only through further investigation will more information regarding this multifactorial disease be revealed. And hopefully someday soon, all the trials, research, and studies will divulge the etiology of anorexia nervosa.
“Anorexic Illustration.” Image from Body Image & Health Task Force. 8 Sept. 2007. <http://www.hec.ohio-state.edu/bitf/anorexia.htm>
“Anorexic Image Two.” Image from Body Image & Health Task Force. 8 Sept. 2007. <http://www.hec.ohio-state.edu/bitf/anorexia.htm>
Bulik, Cynthia M., et al. “The Relation between Eating Disorders and Components of Perfectionism.” The American Journal of Psychiatry 160.2 (2003): 366-369.
Castro-Finieles, Josefina, MD., et al. “Self-Oriented Perfectionism in Eating Disorders.” The International Journal of Eating Disorders 40 (2007): 562-568.
Cockell, Sarah J., et al. “Trait and Self-Presentational Dimensions of Perfectionism among Women with Anorexia Nervosa.” Cognitive Therapy and Research 26.6 (2002): 745-758.
Halmi, Katherine A., et al. “Perfectionism in Anorexia Nervosa: Variation by Clinical Subtype, Obsessionality, and Pathological Eating Behavior.” The American Journal of Psychiatry 157.11 (2000): 1799-1806.
“Kartini Clinic Logo.” Image. 8 Sept. 2007. <www.kartiniclinic.com/college_outpatient.asp>
“Perfect.” Image from jWinters.com Blog. 8 Sept. 2007. <http://jwinters.com/pblog/index.php?d=04&m=09&y=07...>
Physical Effects of Anorexia. Diagram from WomensHealth.gov 8 Sept. 2007. <http://www.helpguide.org/mental/anorexia_signs_symptoms_causes_treatment.htm>
Pieters, Guido L.M., et al. “Action Monitoring and Perfectionism in Anorexia Nervosa.” Brain and Cognition 63.1 (2007): 42-50.
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