Q & A: Clarifying Perfectionism in Anorexia Nervosa

Q: I’ve often heard “perfectionism” referred to as a typical characteristic of patients with anorexia nervosa, but I’ve never been quite sure as to what this perfectionism refers. My own patients with anorexia nervosa seem far from perfect, and many of them seem to have little interest in becoming “perfect.” Can you elucidate? (W.W., West Virginia)

A: “Perfectionism” is a term used to describe a psychological trait with associated behavioral tendencies. It is applied to individuals who believe that perfect states actually exist in certain domains (for example, beauty, physical fitness, academic achievement, the expression of a talent, religious devotion, interpersonal manners, altruism, compassion, etc.), and that one should try to attain these states.

Studies of patients with anorexia nervosa have shown that they tend to score higher than comparison groups on multidimensional measures of perfectionism even after long-term weight recovery. These measures typically assess such qualities as concerns and efforts over avoiding mistakes in daily life and parental criticism, adhering to personal standards and parental expectations, doubting the correctness of one’s own actions, and being organized. Scores on these measures of perfectionism also correlate closely with scores indicating the presence of obsessions and compulsions. Few differences have been found in these dimensions between persons with restricting, binge-eating/purging, and purging subtypes of anorexia nervosa. All show more perfectionism than control women (Am J Psychiatry 2000, 157:1799).

Pertinent to psychotherapy for anorexia nervosa, strongly perfectionistic patients may be highly prone to self-criticism, shame and guilt when they fail to meet their unrealistic standards. Not achieving perfection may be experienced as utter failure, which is an example of “black and white” thinking. In working with such patients, it’s important to appreciate that “Perfect is the enemy of good.”

— J.Y.