Editor’s Note:

Welcome to the forty-fifth edition of the NEDC e-Bulletin. Based on cross-sectional, experimental and longitudinal research, perfectionism is recognised as a risk factor for eating disorder psychopathology. But what exactly is perfectionism and how does it present? This month, we take a closer look at the mindset of perfectionism and seek expert advice from Professor Tracey Wade on treating perfectionism and the impact on eating disorder symptomology.

If you are interested in collaborating with the NEDC, we encourage you to join and become an NEDC member.

Contents:

1. The Perfectionism Mindset
2. Prof. Tracey Wade: Treating Perfectionism and the Impact on Disordered Eating
3. Resource: Eating Disorders in Schools – Prevention, Early Identification and Response

An extensive body of research exists on perfectionism and its potential links to eating disorder onset (Boone, Soenens, Vansteenkiste, & Braet, 2012; Brown, Parman, Rudat & Craighead, 2012; Wade & Tiggemann, 2013;). In light of this, having an understanding of what perfectionism is and how it presents is pertinent to the prevention and management of eating disorders.

What is perfectionism?

A common misconception is that perfectionism is simply ‘doing something perfectly’ (Fursland, Raykos & Steel, 2009). However, perfectionism is much more complex than this. According to widespread research, perfectionism is a personality trait centring on extreme self-pressure to meet increasingly high standards, which powerfully influences the way one perceives themselves (Fursland, Raykos & Steel, 2009; Brown et al., 2012; Wade & Tiggemann, 2013). Bieling, Israeli & Antony (2004) suggest that perfectionism consists of two major components; personal standards (setting and striving for high personal standards and goals) and evaluative concerns (negative reaction to failure, performance doubts and concern over criticism and expectations).

Although perfectionism is defined in different ways among literature, there is general consensus that perfectionism is best understood as a multi-dimensional construct (Brown et al., 2012; Wade & Tiggemann, 2013; Lloyd, Schmidt, Khondoker & Tchanturia, 2015). When measuring perfectionism, researchers often refer to Hewitt and Flett’s (1991) Multi-dimensional Perfectionism Scale. This 45-item measure divides characteristics of perfectionism into three distinct subscales: self-orientated, other-orientated and socially-prescribed. The self-orientated subscale includes items relating to high standards and self-criticism, other-orientated includes items that relate to high expectations of others and socially-prescribed includes items relating to others holding high standards for the individual (Hewitt & Flett, 1991).

Research has shown that perfectionism can be detrimental to an individual’s productivity and self-worth (Lloyd et al., 2015). Dr. Brene Brown (2010), a well-known researcher and public speaker on vulnerability, suggests that perfectionists are often attached to their achievements and argues that there is a clear distinction between helpful pursuit of excellence and unhelpful striving for perfection.

Characteristics of Perfectionism

Perfectionism can present differently in individuals. Current research acknowledges common behaviours and characteristics associated with perfectionism (Fursland et al., 2009; Brown et al., 2012; Wade & Tiggemann, 2013), inclusive of:

• Increasingly high standards
• Fear of failure/ Concern over mistakes
• Procrastination
• Difficulty in decision making
• Reassurance seeking
• Excessive organising or list making
• Self-control
• Overcompensating
• All or nothing thinking

It is important to note that individuals do not have to exhibit all of the aforementioned behaviours, they may only portray one, some or many. In addition to the above, Fursland et al. (2009) argue that rules and assumptions are often evident in individuals with perfectionism, such as; constant checking, should/ must language and the need for structure, order or routine.

The link between eating disorders and perfectionism

Perfectionism has been identified as a potential risk factor for the development of an eating disorder (Boone et al., 2012; Wade & Tiggemann, 2013; Brown et al., 2012). A recent study exploring the role of perfectionism in body dissatisfaction, found that individuals with a lower desired BMI and a smaller ideal silhouette portrayed higher levels of perfectionistic traits, particularly concern over mistakes, organisation and doubt about actions (Wade & Tiggemann, 2013). These findings indicate a negative correlation between perfectionistic characteristics and body image. Additional studies have explored the impact of perfectionism on eating behaviours. Boone et al. (2012) undertook an experimental study, which involved university students being randomly placed in perfectionistic conditions and non-perfectionistic conditions. Results indicated that students placed in perfectionistic conditions reported higher levels of restraint and binge eating over time (Boone et al., 2012). Furthermore, Sassarolli et al. (2008) found that individuals with anorexia nervosa (AN) and bulimia nervosa (BN) showed significantly higher perfectionism traits than controls.

Although evidence acknowledges a relationship between eating disorders and perfectionism, a large body of research also suggests that perfectionism is malleable and therefore a potential target for interventions with eating disorders (Kenneth & Karen, 2002; Wilksch, Burbridge & Wade, 2008).

References

Bieling, P. J., Israeli, A. L., & Antony, M. M. (2004). Is perfectionism good, bad, or both? Examining models of the perfectionism construct. Personality and Individual Differences, 36, 1373–1385.

Boone, L., Soenens, B., Vansteenkiste, M., & Braet, C. (2012). Is there a perfectionist in each of us? An experimental study on perfectionism and eating disorder symptoms. Appetite, 59(2), 531–540.

Brown, A. J., Parman, K. M., Rudat, D. A., & Craighead, L. W. (2012). Disordered eating, perfectionism, and food rules. Eating Behaviors, 13(4), 347–353.

Brown, B. (2010). The Gifts of Imperfection. Hazelden Information & Educational Services; US.

Egan, S. J., Wade, T. D., & Shafran, R. (2011). Perfectionism as a transdiagnostic process : A clinical review. Clinical Psychology Review, 31(2), 203–212.

Fursland, A., Raykos, B. and Steele, A. (2009). Perfectionism in Perspective. Perth, Western Australia: Centre for Clinical Interventions.

Hewitt, P. L., & Flett, G. L. (1991). Perfectionism in the self and social contexts: conceptualization, assessment, and association with psychopathology. Journal of Personality and Social Psychology., 60(3), 456-70.

Kenneth, G., & Karen, J. (2002). The adaptive/ maladaptive perfectionism scale. Measurement and Evaluation in Counselling Development, 34(4), 210–222.

Lloyd, S., Schmidt, U. Khondoker, M., & Tchanturia, K. (2015). Can psychological interventions reduce perfectionism? A systematic review and meta-analysis. Behavioural and Cognitive Psychotherapy, 43(May 2014), 705 – 731.

Sassaroli, S., Lauro, L. J. R., Ruggiero, G. M., Mauri, M. C., Vinai, P., & Frost, R. (2008). Perfectionism in depression, obsessive–compulsive disorder and eating disorders. Behaviour Research and Therapy, 46, 757−765.

Wade, T.D., O’Shea, A., & Shafran, R. (2016). Perfectionism and eating disorders. In F. Sirois & D.S. Molnar (Eds.), Perfectionism, Health, and Well-being (pp. 205-222). Switzerland: Springer.

Waller, G., Shaw, T., Meyer, C., Haslam, M., Lawson, R., & Serpell, L. (2012). Persistence, perseveration and perfectionism in the eating disorders. Behavioural and Cognitive Psychotherapy, 40(4), 462–73.

Wilksch, S. M., Durbridge, M. R., & Wade, T. D. (2008). A Preliminary Controlled Comparison of Programs Designed to Reduce Risk of Eating Disorders Targeting Perfectionism and Media Literacy. Journal of the American Academy of Child and Adolescent Psychiatry, 47(8), 939–947.

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Professor Tracey Wade from the School of Psychology at Flinders University, discusses the impact of treating perfectionism on eating disorder symptomatology. Tracey has worked as a clinician in the area of eating disorders for over 20 years and has co-written two books on perfectionism. Her current research interests are the aetiology, prevention and treatment of eating disorders.

Perfectionism and disordered eating

The connection between perfectionism and disordered eating has been present in theories related to disordered eating for a long time. Hilde Bruch, a German-born American Psychoanalyst, noted that clients with eating disorders demonstrate “superperfection”. Peter Slade, a pioneer in dramatherapy, developed a model which suggested that, in the context of adolescent conflicts, interpersonal problems, and stress and failure experiences, the adolescent with low self-esteem and perfectionistic tendencies would feel a need to try to control or attain success in, at least one salient aspect of life. In the context of our western socio-cultural environment, one of the aspects of life most salient to young women is in the domain of body weight and size. Longitudinal evidence has recently been emerging that shows perfectionism to be implicated in the increase of disordered eating in young women (see Wade, O’Shea & Shafran, 2016, for a detailed review of these studies). Perfectionism has also been included in more recent models of the maintenance of disordered eating, used to formulate treatment approaches. This includes the cognitive behavioural theory, the Maudsley Model of Anorexia Nervosa Treatment for Adults, and the three factor model (Wade, O’Shea & Shafran, 2016). Generally, higher levels of perfectionism are seen to increase levels of disordered eating and make it more difficult to recover from an eating disorder.

Perfectionism and other problems

Perfectionism is associated with higher levels of psychiatric comorbidity (e.g., depression, anxiety, personality disorders), impaired therapeutic alliance, and reduced benefit from evidence based therapies (see Egan, Wade & Shafran, 2011, for a review). Therefore, it is credible to suggest that treating perfectionism may have a variety of benefits for disordered eating, including reducing eating disorder symptoms, reducing comorbidity, and increasing the likelihood that patients may stay in treatment and benefit more from treatment.

Does the research support the idea that treating perfectionism helps with disordered eating?

There are actually very few studies that have addressed the question relating to what degree treating perfectionism impacts on symptoms of disordered eating. Most studies have investigated the impact of cognitive behaviour treatment for perfectionism within more extensive treatment protocols that are focused on treating the disordered eating (e.g., Lloyd, Fleming, Schmidt, and Tchanturia, 2014; Goldstein, Peters, Thorton, and Touyz, 2014; Fairburn et al., 2009; Hurst & Zimmer-Gembeck, 2015).

The only study to date that has used a stand-alone perfectionism treatment for eating disorders was a 6-session guided self-help treatment program (Steele & Wade, 2008). Participants included women with binge/purge forms of eating disorders. Three guided self-help treatments were compared. The first was a cognitive behavioural perfectionism intervention with no eating disorder specific components (CBT-P). The second was a traditional cognitive behavioural therapy focused on eating disorder symptoms (CBT-ED). The third was an active placebo intervention including mindfulness techniques, but not delivered as a program of mindfulness based therapy. There were no significant differences between the groups at the 6-month follow-up. An examination of within-group effect size change between baseline and 6-month follow-up suggested the CBT-ED was more effective than the other two interventions for eating disorder behaviours, namely objective binge episodes and self-induced vomiting. The CBT-P and active placebo intervention were equivalent with respect to impact on behaviours. All three interventions showed commensurate impact on global eating psychopathology. CBT-P performed much better in terms of decreasing depression, anxiety, and perfectionism, and increasing self-esteem, compared to the other two conditions. Across this small body of literature, results are suggestive that CBT for perfectionism could supplement an eating disorder treatment to enhance the outcome, but this has not been tested directly.

What do we know about what happens when you treat perfectionism?

An examination of studies that have examined the impact of perfectionism treatment (called a meta-analysis) has shown that treating perfectionism reliably and significantly decreases perfectionism, depression and anxiety (Lloyd, Fleming, Schmidt, & Tchanturia, 2014). There were insufficient studies to make any conclusions about the impact on eating disorder symptoms. The treatment protocols most commonly evaluated in these studies is based on the clinical perfectionism model (Shafran, Cooper, & Fairburn, 2002), and are outlined in the self-help book Overcoming Perfectionism (Shafran, Egan, & Wade, 2010) and in a therapist manual (Egan, Wade, Shafran, & Antony, 2015).

References

Egan, S.J., Wade TD, & Shafran, R. (2011). Perfectionism as a transdiagnostic process: A clinical review. Clinical Psychology Review, 31, 203-212.

Egan, S.J., Wade, T.D., Shafran, R., & Antony, M. (2014). Cognitive-behavioural treatment of perfectionism. New York: Guilford.

Fairburn, C., Cooper, Z., Doll, H., O’Connor, M., Bohn, K., Hawker, D., Wales, J.A., & Palmer, R. (2009). Transdiagnostic cognitive-behavioral therapy for patients with eating disorders: a two-site trial with 60-week follow-up. American Journal of Psychiatry, 166(3), 311-319.

Goldstein, M., Peters, L., Thorton, C.E., & Touyz, S.W. (2014). The treatment of perfectionism within the eating disorders: A pilot study. European Eating Disorders Review, 22(3), 217-221.

Hurst, K., & Zimmer-Gembeck, M. (2015). Focus on perfectionism in female adolescent anorexia nervosa. International Journal of Eating Disorders, 48(7):936-41.

Lloyd, S., Fleming. C., Schmidt, U., & Tchanturia, K. (2014). Targeting perfectionism in anorexia nervosa using a group-based cogntive behavioural approach: A pilot study. European Eating Disorders Review, 22(5), 366-372.

Lloyd, S., Schmidt, U., Khondoker, M., & Tchanturia, K. (2014). Targeting perfectionism in anorexia nervosa using a group-based cognitive behavioural approach: a pilot study. European Eating Disorders Review, 22, 366–372.

Shafran, R., Cooper, Z., & Fairburn, C.G. (2002). Clinical perfectionism: a cognitive–behavioural analysis. Behaviour Research and Therapy, 40, 773–791.

Shafran, R., Egan, S., & Wade, T.D. (2010). Overcoming Perfectionism. London: Robinson.

Steele, A. L., & Wade, T. D. (2008). A randomised trial investigating guided self-help to reduce perfectionism and its impact on bulimia nervosa: A pilot study. Behaviour Research and Therapy, 46(12), 1316–1323.

Wade, T.D., O’Shea, A., & Shafran, R. (2016). Perfectionism and eating disorders. In F. Sirois & D.S. Molnar (Eds.), Perfectionism, Health, and Well-being (pp. 205-222). Switzerland: Springer.
 

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