The development of perfectionism as a precursor to eating disorders

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CHAPTER 3 DISCOURSES ON PERFECTIONISM

“Have no fear of perfectionism, you’ll never reach it” Salvador Dali (as cited in Oxford Dictionary of Quotations by Subject, 2010, p.358)

Defining perfectionists and perfectionism

Throughout our lives we set goals for ourselves, and standards which we try to maintain. We may wish to become better at a certain skill, excel at a task, maintain a healthy lifestyle, or work to change some aspect of ourselves. Even though such strivings seem normal to most, some individuals become obsessive – improving oneself begins to dominate and control all thoughts and behaviours. Such individuals may be called perfectionists.
David Burn (as cited in Anthony & Swinson, 2009, p.10) defines perfectionism as follows:
“…people whose standards are high beyond reach or reason.” and
“…who strain compulsively and unremittingly towards impossible goals and who measure their own worth entirely in terms of productivity and accomplishment.”
Whilst Kim (2011, para. 5) defines perfectionism as follows:
“Perfectionism is a personality trait that is characterised by striving for extremely high standards, determining self-worth based on ability to achieve high standards, and continuing to strive for certain standards despite the negative consequences.”

Describing perfectionism

Perfectionism is a construct that, over the years, has been conceptualised in several different ways. Personality traits are viewed as stable characteristics that make people unique (Anthony & Swinson, 2009). Generally speaking, perfectionism is a term ascribed to a personality trait which describes individuals who have very specific ideas concerning personal performance, outcomes, and standards in their lives. Such ideas dictate that individuals invest a lot of energy into that particular area of their life – they regard them as high priority and will usually pursue such priorities insistently, even beyond normal healthy limits.
Perfectionists have an intense fear of making mistakes or being judged. They tend to react negatively to manifestations of imperfection and often have discrepancies between self-expectations/standards and their performance (Ingles, Garcia-Fernandez, Vicent, Gonzalvez, & Sanmartin, 2016). For the perfectionist, mistakes and flaws represent failures to live up to their own, or others’ perceived expectations of perfection, and may be seen as evidence of personal deficiencies. As perfectionists’ standards and evaluations are unrealistically high and stringent, perceived failures and negative self-perceptions become very common (Hewitt, Flett, & Ediger, 1995).
Perfectionism has emerged as an important construct with regard to the aetiology and maintenance of various types of psychopathologies (Flett & Hewitt, 2002; Peixoto-Placido, Soares, Pereira & Macedo, 2015). It is often associated with specific psychological problems, including excessive anger, anxiety, social phobia, suicidal behaviour, body image problems, depression and obsessive-compulsive disorder (OCD) (Anthony & Swinson, 2009; Egan, Wade & Shafran, 2011). Anthony and Swinson (2009) identify common areas in life in which unreasonably high standards can lead to problems (i.e. areas prone to perfectionism):

• Performance at work or school.
• Neatness and aesthetics.
• Organisation and ordering.
• Physical appearance.
• Health and personal cleanliness.

Hewitt and Flett (1991b) were amongst the first to conceptualise perfectionism as a multidimensional construct that incorporates self-related and interpersonal trait components, as well as self-presentational components. They identify three types of perfectionism (Flett & Hewitt, 2002):

1. Self-oriented perfectionism

An achievement-based dimension that involves the need for one’s own perfection: Unrealistically high self-imposed standards, which are impossible to obtain. These standards are usually associated with self-criticism, and an inability to accept one’s own mistakes and faults. Negative life events or perceived failures may lead to difficulties with depression. Expectations are self-imposed.

2. Other-oriented perfectionism

An interpersonal dimension that involves the need for others to be perfect: A tendency to demand others to meet your unrealistically high standards. There are thus high expectations which are imposed upon others.

3. Socially prescribed perfectionism

An interpersonal dimension that involves the belief that others expect perfection from oneself: A tendency to assume that others have expectations of you that are impossible to meet. Socially prescribed perfectionists usually believe that to obtain others’ approval, they must meet these high standards. Unlike self-imposed perfectionism, the high standards are not self-imposed, but are rather believed to be imposed by others around you. A perception is held within the individual that expectations of perfection are imposed upon them.
Hill et al. (2004) identified eight different dimensions of perfectionism. These eight dimensions are:

• Concern over mistakes.
• High standards for others.
• Need for approval.
• Parental pressure.
• Striving for excellence.

While Szymanski’s view (2011) identifies six different types of perfectionism:

• The absence of mistakes or flaws.
• Personal standards which are very high.
• Meeting an expectation, set by ourselves or by someone else.
• Order and organisation.
• Ideals that are just right experiences (it looks, feels, and sounds right).
• Absolutes: Knowledge, certainty and safety (to have absolute, complete, and comprehensive knowledge about something – to be convinced that this is the right direction to take. This is a satisfying feeling and comforting – it is a 100% guarantee. Another variation on this is when people chronically doubt their actions).
• Being the best and the best of the best.

Anthony and Swinson (2009) view perfectionism rather as a single construct with six dimensions. These dimensions include the following:

• Concern over mistakes (tendencies to be overly concerned about making mistakes).
• Personal standards (to have overly high personal standards).
• Doubts about actions (to doubt whether one has done things correctly).
• Organisation (to have an extreme need for organisation).
• Parental expectations (to have parents with unreasonably high expectations).
• Parental criticism (to have parents who are overly critical).

Regardless of whether one views perfectionism as a single concept, or as consisting of several related dimensions, most definitions appear to share the following features (Anthony & Swinson, 2009):

• Individuals who are perfectionistic tend to have standards and expectations that are very difficult, or impossible to meet.
• Although having high standards is often helpful, perfectionism is associated with having standards that are so high that they interfere with overall performance.
• Perfectionism is often associated with other problems such as anxiety or depression.

In addition to the trait dimensions of perfectionism, Hewitt, Flett and Fairlie (as cited in Hewitt et al., 1995) also describe social facets of perfectionism. This involves self-presentational styles where the individual strives to create an image of flawlessness to others. Their research into perfectionistic self-presentation identifies three major components to this construct:

• The need to appear perfect.
• The need to avoid appearing imperfect.
• The need to avoid disclosure of imperfection.

Taking all the above-mentioned information into account, an operational definition of perfectionism is understood as a desire for perfection, a fear of imperfection, the equating of error to personal defectiveness, or the emotional conviction that perfection is the route to personal acceptance. It influences multiple areas of the person’s thinking, with a strong intrinsic need to refrain from being viewed as imperfect, or noticing any personal defect within themselves.

Diagnosing perfectionism

At the extreme end of this personality trait (i.e. perfectionism) is what may be termed ‘clinical perfectionism’. At this level, the trait is so pronounced that the impairment caused by perfectionism in the sufferer’s life is significant (Shafran, Cooper, & Fairburn, 2002). Anthony and Swinson (2009) associate perfectionism with a range of psychological issues:

• Depression
• Perfectionistic thoughts and behaviours are often important in the maintenance of depression. Setting high standards and not achieving them contributes to feelings of inadequacy, disappointment and
• hopelessness.
• Perfectionism has previously been recognised as a contributory regarding the maintenance of depression and anxiety disorders (Maloney, Egan, Kane & Rees, 2014).
• Generalised anxiety and worry
• Not meeting the self-imposed standards for yourself (or others) may cause possible anxiety.
• Social anxiety and shyness
• Fear around people and that one will be judged for not meeting the standards one feels others impose on one.
• Anger
• Inflexible beliefs and  imposing  that  way  of  thinking  on  situations  and others (and oneself).
• When one does not meet the standard, then one can become angry because it is so important for one.
• Obsessive-compulsive disorder
• Perfectionism helps with maintaining OCD because compulsions need to be repeated over and over until they feel right. Also, the order in which activities are repeated or completed may also be inflexible.
• Body-image problems
• People with eating disorders are inflexible and rigid with their rules about eating and food.
• The excessive focus can be on aspects of food, weight, or a particular body part.

Anthony and Swinson (2009) stress the importance of understanding to what extent one’s beliefs are inflexible: The more inflexible one’s beliefs, and the more situations in which one has inflexible opinions, the more likely one is to struggle with perfectionistic thinking. In trying to understand the appropriateness of one’s beliefs, Anthony and Swinson (2009) apply four key areas to assess the appropriateness of one’s beliefs about standards and performance:

• The excessiveness of the standard. “Can this goal really be met?”
• The accuracy of the belief. “Is it true that this standard has to be met before someone will accept me?”
• The costs and benefits of imposing the standard. “Does it help me in life to have this belief or standard?”
• The flexibility of the standard or belief. “Can I adjust my standards and beliefs when necessary?”

At the heart of clinical perfectionism is the over-evaluation and over-dependence of achieving and achievement. Individuals judge themselves largely, or exclusively, in terms of working hard toward, and achieving personally demanding standards in areas of life deemed as extremely important. Their self-worth is dependent on achievement, and is a core maintaining factor in clinical perfectionism. The efforts towards achievement are rigorous, despite having adverse effects on actual performance, and being made at the expense of other important areas of functioning in the individual’s life (Shafran et al., 2002).
Burns (1980) maintains that perfectionism involves the compulsive pursuit of goals which are unrealistically high, and is learned from interactions with perfectionistic parents. He identified five categories of perfectionists (Burns, 1983):

• Career perfectionists (compulsive belief that they need to be successful in all their professional activities).
• Marital- or interpersonal perfectionists (compulsive belief that husbands and wives should never fight, for conflicts reflect badly on relationships).
• Emotional perfectionists (compulsive belief that they need to be happy all the time and never have any negative feelings).
• Moral perfectionists (compulsive belief that they need to punish themselves relentlessly whenever they fail to meet any moral standards, as well as not knowing how to forgive themselves).
• Sexually perfectionistic women (belief that they are defective if they have difficulty in reaching an orgasm, or that their worth depends primarily upon their appearance). Sexually perfectionistic men (belief that they must always perform well during sex).

How one becomes a perfectionist will be described next. Consideration will be made to understanding its influence as a precursor to the development of eating disorders.

The development of perfectionism as a precursor to eating disorders

According to Anthony and Swinson (2009), attempts to find the exact origins of perfectionism have found that both internal- and external factors may be contributors. A review of literature from multiple researchers highlights the following list of factors that may contribute to the development and maintenance of perfectionism, as a precursor to developing an ED:

• Culture
• Nielsen (2000) stresses the influence of Western standards of beauty and how they have become increasingly focused on a woman’s thinness.

These standards of beauty seem to have influenced women and men during the time of the emancipation of white women in developed countries after they were granted the right to vote, started working outside the home in large numbers, and became equal to white men in terms of college graduation rates.
Browne (1993) highlights the correlation between black women who identify with, or interact with, white upper class culture, and the increased possibility that they are to adopt white attitudes to physical appearance. These attitudes are such that among many upwardly mobile black Americans, a woman with a heavy body and large hips is considered more lower class looking than a skinny woman.
From the general association of extreme thinness with poverty, it may be understood that AN would be more prevalent in people with low income and socio-economic status. However, its high prevalence in middle to upper class and its colloquial label as a disease of affluence, are indicative of a paradoxical relationship with economic status. Selvini-Palazzoli (1985) asserts that the culture of affluent consumerism presents a strong contradiction in that as food becomes more abundant, so does the demand for self-discipline, and the obligation to be thin increases as well.

• The mass media
• The role of mass media in the incidence and prevalence of AN has been widely contended. Some regard the media as the purveyor of images to the public while others see the media as a symptom of a much deeper underlying cause.
• Media exposure, perceived pressure to be thin, thin-ideal internalisation and thinness expectancies have all been shown to prospectively predict increased levels of disordered eating thinking and behaviours, such as body dissatisfaction, dieting and bulimic symptoms in adolescent and young females (Culbert et al., 2015).
• In a study focusing on the relationship between media use and disordered-eating, Harrison and Cantor’s (1997) content analysis of television programming revealed that 69% of female characters were thin, compared to 17% male. Similarly, when comparing women’s- and men’s magazines, on average, ten times more dieting articles and adverts were featured in women’s magazines.
• Dietz (1990) concluded that on an annual average, children and adolescents spend more time watching television than any other activity including being at school, with sleeping time being the only exception. Thus, television serves as a major source of information about the world, behaviour and appearances. By consistently featuring diet adverts and articles, the media is highly implicated in the development of eating disordered attitudes and behaviours.
• Information and instruction: Being bombarded with standards about physical attractiveness by people in advertising, media, movies, and catalogues. This exposure to information in the media, talking to other people, or other sources may be information which encourages a perfectionistic outlook on life (Anthony & Swinson, 2009).
• Social learning and influences
• Parental bonding can be considered one of the most widely recognised aetiological factors regarding perfectionism. Parental expectations as well as parental criticism play an integral role in the development of perfectionism (Maloney et al., 2014). Modelling serves as a mechanism for learning perfectionism from other important people in one’s life. This includes developing adverse ways of managing fear or trying to achieve approval from others (Anthony & Swinson, 2009).
• Harrison and Cantor (1997) used Bandura’s 1997 social learning theory to account for the process by which the thin body ideal and extreme dieting behaviour is promoted in the media through prevalence and depiction. They established a positive correlation between the prevalence of diet-related images, adverts, thin-bodied models/characters and the modelling of extreme dieting behaviours. Anticipated external rewards such as social acceptance and fame serve as incentive and reinforcement for such behaviours.
• Levine (2000) stresses that the association with the thin ideal is more from the internalisation of this ideal, rather than the mere depiction or viewing of such media images. He does, however, acknowledge that by their emphasis on physical beauty, these images foster self-evaluation and self-development along unattainable ideals, which may pressure women to attempt harmful means to their attainment.

A perfectionistic personality style has been described frequently as a central feature of eating disorders. Several theorists such as Bruch and Casper (as cited in Hewitt et al., 1995) have hypothesised a pathogenic role for perfectionistic tendencies in eating disorders. Previous research by Garner, Olmsted, Polivy, and Garfinkel (as cited in Hewitt et al., 1995) have supported the view that individuals with an ED have unrealistic standards for physical attractiveness and thinness, as well as having a disposition involving unrealistic expectations and strivings in various situations (Strober, as cited in Hewitt et al., 1995). Also, perfectionism has been highlighted in Fairburn’s transdiagnostic model of eating disorders (Fairburn, 2008), as well as the cognitive-interpersonal maintenance model of AN (Lavender et al., 2016).

List of Figures 
List of Tables 
List of Acronyms 
Chapter 1 Introduction
1.1 Reflecting on eating disorders as complex condition
1.2 A personal reflection of the experienced world of those with treatment resistant eating disorders, and its influence in developing the research idea
1.3 The problem statement
1.4 Objectives of the research
1.5 Reasons for the necessity of this research
1.6 Layout of chapters
Chapter 2 Discourses on Eating Disorders
2.1 Describing, defining and categorising eating disorders 23 2.1.1 Diagnosing Anorexia Nervosa (AN)
2.2 The consequences of eating disorders
2.3 The short history of eating disorders
2.4 Modern conceptions of eating disorders
2.4.1 Prevalence rates
2.5 Assessing eating disorders
2.6 Managing eating disorders
2.7 Treating eating disorders
2.8 Psychological treatment perspectives for eating disorders 98 2.8.1 Psychodynamic perspectives on eating disorders
2.9 Eating disorders research in South Africa
2.10 Eating disorders management and treatment
Chapter 3 Discourses on Perfectionism
3.1 Defining perfectionists and perfectionism
3.2 Describing perfectionism
3.3 Diagnosing perfectionism
3.4 The development of perfectionism as a precursor to eating disorders
3.5 Clinical perfectionism in eating disorders
3.6 Assessing perfectionism
3.7 Methodological issues in the study of perfectionism within eating disorders
Chapter 4 Research Paradigm and Methodology
4.1 Qualitative research methods
4.2 The foundational development of the research study design
4.3 The research study design
4.4 Selection procedure
4.5 Data collection procedure
4.6 Data analysis procedure
4.7 Issues of generalisability, validity and reliability, as well as rigor and trustworthiness of the research design
Chapter 5 Presentation of the Phenomenological findings
5.1 My personal reflections (Epoché)
5.2 Procedure for presenting the findings
5.3 Demographic profiles of the research participants
5.4 Phenomenological descriptions of each participant’s experiences
5.5 A general structural description of the phenomenon of perfectionism in treatment resistant eating disorder clients
Chapter 6 Presentation of the findings according to the Grounded Theory analysis
6.1 Introduction
6.2 Grounded theory of perfectionism within treatment resistant eating disorders: The Perfectionistic Eating Disorders Self-Schema (PEDSS)
Chapter 7 Discussion of the research findings
7.1 Legitimising this study’s claims toward valid knowledge through current research
7.2 Discussion of the phenomenological findings
7.3. Second phase literature review
7.4 Discussion of the grounded theory findings: Placing the emergent PEDSS theory within the context of existing literature on perfectionism
7.5 Discussion of the integrated findings: Understanding perfectionism in treatment resistant eating disorder clients through the experiences of the participants and The Perfectionistic Eating Disorder Self-Schema (PEDDS)
Chapter 8 Conclusions and Recommendations
8.1 Perfection in treatment resistant eating disorder clients
8.2 Results of the phenomenological approach to exploring perfectionism in  treatment resistant eating disorder clients
8.3 Results of the grounded theory approach to exploring perfectionism in treatment resistant eating disorder clients
8.4 Value of the research
8.5 Strengths of the research
8.6 Limitations of the research
8.7 Recommendations for future research
8.8 Final conclusions of the research
Appendices
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Perfectionism: An exploratory analysis of treatment resistant eating disorder clients during intervention.