Review articlePerfectionism and eating disorders: Current status and future directions
Introduction
Perfectionism has long been linked to eating disorders. Indeed, eating disorder pioneer Hilde Bruch characterized young anorexia nervosa (AN) patients as fulfilling “every parent's and teacher's idea of perfection” and demonstrating “pleasing superperfection” (Bruch, 1978, p. 59). While the link with AN is longstanding and broadly accepted, the relation of perfectionism to bulimia nervosa (BN) is less clear. Some, however, suggest that the common central features of both AN and BN (in particular, striving for a “perfect” weight or body shape) are inherently perfectionistic (Goldner, Cockell, & Srikameswaran, 2002). Importantly, a recent proposal in the treatment of eating disorders has identified perfectionism as a key maintenance mechanism that may help account for the persistence of severe eating disorders (Fairburn, Cooper, & Shafran, 2003).
Three extensive reviews have considered the role of perfectionism in eating disorders. Jacobi, Hayward, de Zwaan, Kraemer, and Agras (2004) concluded that empirical work supports perfectionism as a correlate in the context of cross-sectional designs and (the few existing) longitudinal designs, and as a specific correlate in studies retrospectively assessing perfectionism. In his meta-analytic review, Stice (2002) found that the effect of perfectionism on maintenance of eating pathology was medium in magnitude, and the effect on increases in eating pathology (in particular, bulimic symptoms) was small, but significant. Stice suggested that perfectionism may be a risk factor for bulimic symptoms and a maintenance factor for more general eating pathology, and that perfectionism may interact with other risk factors in producing or maintaining eating pathology (e.g., Vohs, Bardone, Joiner, Abramson, & Heatherton, 1999). In their review of personality and eating disorders, Lilenfeld, Wonderlich, Riso, Crosby, and Mitchell (2006) concluded that the limited prospective research suggests that perfectionism may be a predisposing personality trait, preceding and increasing risk for the development of an eating disorder.
Despite general clinical and empirical consensus that perfectionism has a role in eating disorders (in particular, AN), the various research findings have yet to be collectively presented in a manner that produces a clear picture of what empirically oriented questions are being asked about perfectionism and eating disorders, and what the data are indicating. This review explicitly lays out the key research questions being addressed in the literature and summarizes the relevant empirical findings. Also, research on perfectionism in anxiety disorders and depressive disorders is reviewed to provide comparisons to the perfectionism–eating disorders literature. Finally, Enns, Cox, and Borger (2001) reported potential differences in the operation of perfectionism in analogue versus clinical samples. Consequently, in this review we focus exclusively on studies using diagnosed samples. Reviewing the multitude of studies of eating and perfectionism among nonclinical participants may present an inaccurate picture of perfectionism in eating disorders.
Any review related to perfectionism must grapple with the problems of defining and assessing perfectionism. Prior to the 1990's, assessment measures for perfectionism reflected a unidimensional construct. For example, one of the earliest perfectionism measures, the Burns Perfectionism Scale (Burns, 1980), focused on perfectionism as reflecting unremitting striving for unreasonably high standards and assessing one's worth based on accomplishment. The most commonly used assessment of perfectionism in the eating disorder literature comes from the Eating Disorder Inventory (EDI; Garner, Olmsted, & Polivy, 1983). While developed as a measure of general perfectionism yielding one score, researchers have since demonstrated that the EDI-Perfectionism subscale may better fit a two-factor model, including self-oriented perfectionism and family-pressured perfectionism (Joiner and Schmidt, 1995, Sherry et al., 2004). Both of these measures have satisfactory psychometrics (Enns & Cox, 2002).
In the early 1990's, multidimensional conceptualizations of perfectionism led to the development of new instruments, including the Frost Multidimensional Perfectionism Scale (Frost MPS; Frost, Marten, Lahart, & Rosenblate, 1990) and the Hewitt and Flett Multidimensional Perfectionism Scale (Hewitt and Flett MPS; Hewitt & Flett, 1991a). Both instruments have been used extensively and have good psychometric properties (Enns & Cox, 2002), and both address interpersonal aspects of perfectionism. Briefly, the Frost MPS provides scores for total perfectionism and for six dimensions of perfectionism, conceptually labeled Concern Over Mistakes (CM), Personal Standards (PS), Parental Criticism (PC), Parental Expectations (PE), Doubts About Actions (DA), and Organization (O). The Hewitt and Flett MPS is composed of three dimensions reflecting the personal and social components of perfectionism: Self-Oriented Perfectionism (SOP; reflecting one's personal setting of high standards), Socially Prescribed Perfectionism (SPP; reflecting perceived high expectations from others of oneself), and Other-Oriented Perfectionism (OOP; reflecting one's high expectations for others). (See Table 1 for a list of key perfectionism acronyms used in this review.)
In the past decade additional perfectionism measures have emerged with adequate psychometric properties and different conceptualizations of perfectionism. The Almost Perfect Scale—Revised (APS—R; Slaney, Rice, Mobley, Trippi, & Ashby, 2001) seeks to discriminate between adaptive and maladaptive perfectionism and includes a discrepancy subscale that assesses distress caused specifically by the mismatch of standards and performance. The perfectionism subscale of the Obsessive Beliefs Questionnaire (OBQ-Perfectionism; Obsessive Compulsive Cognitions Working Group, 2001) is part of a larger measure of obsessive compulsive beliefs. It is consistent with the maladaptive perfectionism dimension and the tendency to avoid mistakes and failure. The Perfectionism Cognitions Inventory (PCI; Flett, Hewitt, Blankstein, & Gray, 1998) reflects a cognitive focus, assessing frequency of perfectionistic automatic thoughts, and has been found to account for unique variance in distress beyond that accounted for by trait perfectionism dimensions (Flett et al., 1998).
Various studies using multidimensional measures of perfectionism suggest that there are two factors underlying the multidimensionality. Conceptually, this harkens back to Hamachek's (1978) distinction between neurotic perfectionism (striving for excessively high standards is motivated by fear of failure) and normal perfectionism (striving for reasonable standards leads to satisfaction), as well as ideas of negative perfectionism (perfectionistic behavior that is driven by negative reinforcement) and positive perfectionism (perfectionistic behavior that is driven by positive reinforcement) (Terry-Short, Owens, Slade, & Dewey, 1995). More generally, theorists have described maladaptive and achievement striving components of perfectionism (e.g., Slaney et al., 2001). Empirically, factor analytic work involving the items from the Frost MPS and the Hewitt and Flett MPS has found support for two factors, conceptually labeled Maladaptive Evaluative Concerns (consisting of CM, DA, PC, and PE from the Frost MPS, and SPP from the Hewitt and Flett MPS) and Positive Striving, which will be referred to as Achievement Striving in this paper, (consisting of PS and O from the Frost MPS, and SOP and OOP from the Hewitt and Flett MPS) (Frost, Heimberg, Holt, Mattia, & Neubauer, 1993). Bieling, Israeli, and Antony (2004) used versions of the factors derived by Frost et al. (1993) to find that the Maladaptive Evaluative Concerns dimension was more strongly associated with measures of psychological distress than was the Achievement Striving dimension. This finding, along with other findings related to multidimensional perfectionism and maladjustment, led Bieling and colleagues to conclude that CM, DA, PC, PE, and SPP reflect maladaptive perfectionism while PS and SOP, reflect, if not an adaptive component, then at least a more benign one, not associated with distress. In this review we will primarily discuss findings in terms of the two underlying dimensions of maladaptive and achievement striving perfectionism but we will also refer to specific dimensions of perfectionism (i.e., PS, CM, SOP, SPP, etc.) to highlight findings involving specific subscales. Unidimensional measures of perfectionism like the Burns Perfectionism Scale, the EDI-Perfectionism subscale, and OBQ-Perfectionism contain a mixture of maladaptive and achievement striving items, though they appear somewhat more closely associated with maladaptive perfectionism (Frost et al., 1990).
The current review was guided by two objectives. First, we wished to examine rigorously the existing empirical literature addressing the relation between perfectionism and eating disorders, particularly in terms of: 1) identifying the central questions being posed by eating disorder researchers, and then summarizing the data addressing these questions, and 2) identifying methodological characteristics of these studies. Second, we wished to compare the study of perfectionism in the eating disorder literature to the study of perfectionism in the anxiety disorder and depressive disorder literatures. Our findings and insights from these other literatures, in conjunction with our review of the eating disorder literature, raise critical conceptual and methodological issues for the study of perfectionism in the eating disorders.
Section snippets
Methods
We began with a systematic review of the published empirical work on perfectionism and eating disorders. Literature searches were conducted using PsychInfo for the years 1990 through 2005. The year 1990 was selected as the start date for this search since assessment instruments looking at perfectionism multidimensionally emerged in the early 1990's, leading to a substantial increase in perfectionism research. For example, a PsychInfo search using “perfectionism” and “anorexia” yielded over 90
Results
The literature search for empirical articles meeting inclusion criteria resulted in 55 studies addressing the relation between perfectionism and diagnosed eating disorders, with the majority of these involving clinical samples rather than population or community samples. Based on an initial review of these articles, the authors identified nine research questions that were addressed by these studies. These papers were then reviewed comprehensively in terms of methodology and results. Each of the
Conclusions
A review of the literatures on the relation between perfectionism and diagnoses of eating disorders, anxiety disorders, and mood disorders illuminates the directions eating disorder research has taken and sheds light on future directions. In some areas, the eating disorder literature appears to be progressing more than the other literatures — for example, in attempts to consider premorbid perfectionism (e.g., Fairburn et al., 1999) and familial patterns of perfectionism (e.g., Lilenfeld et al.,
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