Jenna DiLossi, PsyD, ABPP
Whether they have directly treated eating disorders (EDs) or not, most clinicians are aware of the challenges facing individuals within this community. In addition to medical sequalae and psychiatric comorbidity, there are many notable clinical features that manifest within the presentation and maintenance of EDs. Maladaptive perfectionism, a known clinical feature in EDs, typically presents as a combination of self-evaluation with harsh self-criticism and unrelenting standards that are often inflexible, unreasonable, and leave no room for error (DiBartolo et al., 2008).
There are a number of ways that perfectionism relates to disordered eating. Several studies have identified perfectionism as a variable involved in the onset and maintenance of EDs (e.g., Wade et al., 2016), and it contributes to treatment outcomes. Cognitive-Behavior Therapy-Enhanced (CBT-E; Fairburn, 2008), an evidence-based treatment, includes clinical perfectionism as a module within the broad form of the treatment protocol.
How Does Perfectionism Directly Maintain ED Behavior?
Perfectionism not only plays a role in general prevalence and intensity of EDs but also in how specific ED behaviors present. A link between perfectionism and anorexia nervosa (AN), specifically, has been recognized for a long time. For example, it is not uncommon for individuals with perfectionism to internalize the value of thinness, a fairly prevalent ideal in our society, and to adopt beliefs and behaviors associated with the “perfect diet” and the “perfect body.” This belief system and corresponding behavioral pattern make one especially vulnerable to developing AN in adolescence or young adulthood. Once the effects of starvation and low body weight kick in, individuals with AN tend to become increasingly anxious and perfectionistic. Increased perfectionism unfortunately tends to further increase the intensity of AN cognitions and behaviors over time. Interventions that aid in increasing food intake and subsequent weight gain are imperative to break this cycle. Psychoeducation (including the effects of being underweight), self-monitoring, establishing a schedule of regular eating, and food exposure are helpful here. Additionally, involving loved ones in treatment can be particularly helpful in cases of AN.
The link between perfectionism and bulimia nervosa (BN) is slightly less clear. A common theme between perfectionism and BN relates to striving for a “perfect body,” as seen in AN. This domain of perfectionism often presents as having unrelenting standards regarding eating behaviors and actions that impact body image. As a result of such standards, individuals with EDs often engage in an unhealthy degree of dietary restraint, under-eating, rigid exercise regimens, and other destructive behaviors believed to impact their body image (e.g., self-induced vomiting). There is also a pattern of self-defeating dichotomy in their thinking and behavior (Lethbridge et al., 2011). The combination of dietary restraint, under-eating, and perfectionistic thinking (e.g., “I can’t have any sugar at all today”) creates a perfect storm for binge-eating to occur. A patient who makes the decision to binge-eat after having one cookie because “the day was already ruined” is a classic example of how clinicians see perfectionism manifest in BN maintenance. While it may seem illogical to equate eating one cookie to eating a whole box of cookies, it is not unusual for individuals with BN to truly believe that an entire day has been tarnished from even the slightest break in their self-prescribed rules. Clinicians can employ techniques like self-monitoring and establishing regular eating, psychoeducation about the relationship between restraint and binge-eating, and collaborative weighing.
How Does Perfectionism Indirectly Maintain ED Behavior?
Another notable way that perfectionism pertains to disordered eating relates to personal identity, morals, and values. This relationship presents similarly to morality-based obsessionality in obsessive-compulsive disorder (Reuven et al., 2014. In the case of EDs, it is not unusual for individuals to present with extremes in their beliefs about personal morality and restraint with food and eating behaviors. Clients hold beliefs related to indulgence and self-control as they relate to morals and “who I am as a person.” In these examples, clients usually believe that one’s ability to practice restraint relating to pleasure is indicative of self-control and discipline, which then equates to being a “good” person. Conversely, giving into indulgences implies a lack of self-control and gluttony, which equates to being a “bad” person. Behavioral experiments involving eating indulgent foods followed by Socratic questioning about the implications of such behavior is a helpful strategy to address maladaptive beliefs.
It is also worth mentioning that perfectionism often extends to interpersonal relationships and tasks related to achievement for individuals with EDs (Shafran et al., 2002). Clinicians often describe their patients with EDs as “people pleasers” and “over-achievers.” This is not surprising as likeability and achievement are often linked to our society’s definition of success. Of course, perfectionism within these domains is widespread in our mainstream culture and is not necessarily indicative of psychopathology. But individuals with Eds tend to hold perfectionistic beliefs that are often connected to their eating behaviors. The broad form of CBT-E identifies interpersonal relationships and perfectionism as potential domains to target in treatment. The goal is to help patients “strengthen their muscles” of tolerance for imperfection within interpersonal relationships and achievement. Useful strategies include assertiveness training, behavioral experiments and exposures to being “rude” or “selfish,” and psychoeducation about healthy relationships. Behavioral experiments involving completing tasks with a standard of “good enough,” an examination of values-based self-evaluation, and cognitive restructuring for beliefs pertaining success can be used to address achievement-based perfectionism.
While it may appear at face value that perfectionism aids success in life, it tends to be largely self-defeating and may prevent individuals from reaching their true potential across many domains of their lives. Perfectionism—within and outside of EDs—usually results in a never-ending cycle of self-criticism, anxiety, guilt, and frustration, significantly impacting one’s quality of life. In cases of EDs, perfectionism has the potential to seriously impair individuals’ day-to-day functioning by maintaining several types of pathological eating and behavior.
A number of cognitive-behavioral interventions, along with a variety of evidence-based techniques (integrated into CBT according to an ongoing individualized cognitive conceptualization of the patient), are important to treat individuals with ED. Clinicians need to establish strong therapeutic relationships with their clients to elicit their cooperation. Reference to their life aspirations and most important values can motivate them to do the hard work of therapy. Understanding the notable role that perfectionism plays within patients’ individual ED onset and maintenance and decreasing maladaptive perfectionistic beliefs and behavior can make therapy more effective.
References:
DiBartolo, P. M., Li, C. Y., & Frost, R. O. (2008). How do the dimensions of perfectionism relate to mental health? Cognitive Therapy and Research, 32(3), 401-417.
Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. Guilford Press.
Lethbridge, J., Watson, H. J., Egan, S. J., Street, H., & Nathan, P. R. (2011). The role of perfectionism, dichotomous thinking, shape and weight overvaluation, and conditional goal setting in eating disorders. Eating behaviors, 12(3), 200-206.
Reuven, O., Liberman, N., & Dar, R. (2014). The effect of physical cleaning on threatened morality in individuals with obsessive-compulsive disorder. Clinical Psychological Science, 2(2), 224-229.
Shafran, R., Cooper, Z., & Fairburn, C. G. (2002). Clinical perfectionism: a cognitive-behavioural analysis. Behaviour research and therapy, 40(7), 773–791.
Wade, T. D., O’Shea, A., & Shafran, R. (2016). Perfectionism and eating disorders. Perfectionism, health, and well-being, 205-222.