Perfectionism in Eating Disorders

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Perfectionism–the tendency to hold unrealistically high standards–has been implicated in the development of and maintenance of eating disorders. Clinical perfectionism is a primary target of intervention in Cognitive Behavioral Therapy (CBT-E), the leading treatment for adults with eating disorders. Studies have shown that patients with anorexia nervosa and bulimia nervosa have higher levels of perfectionism than control subjects. Perfectionism has been less studied but also identified in patients with binge eating disorder. According to Bardone-Cone and colleagues (2010), “perfectionism appears to play a role in the etiology, maintenance, and treatment of eating disorders” (p. 139). This article will define perfectionism, describe its relationship to eating disorders, and discuss treatment strategies.

What Is Perfectionism?

Perfectionism is a complex personality characteristic with no universally accepted definition. It is sometimes viewed as a personality trait or symptom. It can also be understood as a process. Perfectionism can have positive and negative aspects. Having high standards can be an asset and in many cases, it can be helpful in attaining goals. However, perfectionism also exacts a cost and in the wrong situations, too much of it can be an impediment. The perfectionism associated with psychological problems is problematic and has been referred to as clinical (or dysfunctional) perfectionism.

Clinical perfectionism has three aspects:

  1. The continuous expectation that you or others meet high standards that, given the circumstances, other people consider extreme or unreasonable.
  2. Judging your self-worth largely on your ability to strive for and achieve these unrelenting high standards.
  3. Continuing to aim for these standards despite consistently negative consequences.

People can exhibit perfectionism in certain domains of their lives and not in others. For example, some people are perfectionistic regarding school or work, but not around their homes. Others may be perfectionistic around their appearance, but not about their school or work performance. Specific domains of perfectionism that have been identified in the literature include:

  • Performance at work or school
  • Close relationships
  • Leisure and athletics
  • Neatness and aesthetics
  • Organization and ordering
  • Writing
  • Speaking
  • Physical appearance
  • Health and personal cleanliness

People with perfectionism engage in certain behaviors that maintain their perfectionistic beliefs. Perfectionistic behaviors include both things you might do and things you might avoid doing.

Behaviors that perfectionists might do include:

  • Excessive checking
  • Excessive organizing
  • Listmaking
  • Correcting others

In addition, many people with perfectionism avoid doing certain things out of fear that they will not be able to meet their own standards. Examples of avoidance behaviors include:

  • Giving up too soon
  • Indecisiveness
  • Avoiding tasks
  • Failure to delegate
  • Procrastination

Many people with clinical perfectionism find that it negatively affects their social relationships, mental health, and/or physical health. 

Perfectionism’s Relationship to Eating Disorders

Perfectionism and eating disorders seem to be correlated, but the causality is not clear–we don’t know if one leads to the other or which comes first. Some research indicates that people with eating disorders and perfectionism often displayed perfectionistic traits before their eating disorders began. Some research studies showed that perfectionistic traits persisted in individuals with eating disorders even after recovery. However, Bardone-Cone and colleagues found that when a more stringent definition of eating disorder recovery was used, perfectionistic symptoms were reduced to levels similar to those found in patients without eating disorders. These researchers write, “From this perspective, interventions and/or experiences that help decrease perfectionism may be key to making full recovery attainable. However, it could also be that the temporal ordering is reversed, with attaining full eating disorder recovery (with eating disorder symptomatology at levels comparable to those with no history of an eating disorder) being what permitted the relaxation of perfectionistic standards and attitudes.”

Clinical perfectionism is described as one of four key factors that maintain eating disorders, according to Fairburn, the author of CBT-E. Research shows perfectionism is related to poorer prognosis after admission for anorexia nervosa and with higher treatment drop-out.

Treatment

If relaxation of perfectionism is associated with a more complete eating disorder recovery, it deserves attention during treatment. Most of the research on the treatment of perfectionism has focused on cognitive behavioral therapy (CBT) approaches. CBT treatment for perfectionism has been found to be successful in reducing perfectionism among both patient and nonpatient populations. It has also has been shown to reduce eating disorder symptoms as well as symptoms of other disorders including depression and anxiety.

CBT treatment for perfectionism involves challenging perfectionistic thoughts such as all-or-nothing thinking and “should” statements. It involves identifying overgeneralizations and double standards. Patients also learn to test perfectionistic beliefs through the use of behavioral experiments. For example, a patient who believes he would be too ashamed to ever have a friend over unless his apartment is totally and thoroughly cleaned up could test having a friend over when things are left out of place. A client could test the belief that she must always be productive by scheduling time to sit in the park and people-watch.

Having a problem with perfectionism is similar to having a “phobia” of being imperfect–you are terrified of making mistakes. Treatment for this condition therefore also involves repeated exposure to situations in which you are unlikely to perform perfectly. Examples of exposure activities could include:

  • Arriving late for an appointment
  • Sending out an email that includes a spelling or grammatical error
  • Speaking in a meeting and losing your train of thought
  • Asking for help in a store
  • Giving incorrect change when paying for something

Over time, with repeated exposure, patients learn that it is safe to relax their standards and that nothing terrible happens when they do. The goal is to develop more healthy and balanced standards.

Will Treatment Help Me?

Given the link between perfectionism and eating disorders, it might help to recognize and address perfectionism in you or a loved one. The following are questions suggested by one of the leading experts on perfectionism (Antony, 2015) to assess whether one might need help for perfectionism:

  • Are my standards higher than those of other people?
  • Am I able to meet my standards? Do I get overly upset if I don’t meet my own standards?
  • Are other people able to meet my standards? Do I get overly upset if others don’t meet my standards?
  • Do my standards help me to achieve my goals or do they get in the way (e.g., by making me overly disappointed or angry when my standards are not met; by making me get less work done, etc.)?
  • What would be the costs of relaxing a particular standard or ignoring a rule that I have?
  • What would be the benefits of relaxing a specific standard or ignoring a rule that I have?

In Summary

If you or a loved one with an eating disorder displays symptoms of perfectionism, you might want to seek help for these symptoms in addition to seeking treatment for the eating disorder. Successful CBT self-help programs for perfectionism include the book When Perfect Isn’t Good Enough and Perfectionism in Perspective, a free online downloadable workbook. 

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View Article Sources
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