A longitudinal study of perfectionism in adolescent onset anorexia nervosa-restricting type

Eating behaviours and personality characteristics of clinicians and researchers working in eating disorders

Disturbances in eating behaviours and differences in personality characteristics, such as perfectionism, cognitive flexibility, and obsessive-compulsive behaviours, are commonly reported in individuals with eating disorders (ED) and can influence the development and maintenance of EDs. The presence of these characteristics in ED professionals may also have an influence on their patients. The aim of this study was to gain a better understanding of the presence of these behaviours and characteristics in ED clinicians/researchers (EDCR). This study examined whether these constructs differed amongst 83 EDCR and 47 general mental health clinicians/researchers (MHCR), who completed an online survey, measuring eating disorder symptomology, orthorexia nervosa, perfectionism, cognitive flexibility, and obsessive-compulsive traits. Significantly less dietary restraint, eating concerns and orthorexia nervosa behaviours, but significantly poorer ability to seek out alternative solutions (i.e. a component of cognitive flexibility) were found in the EDCR group compared with the MHCR group. Moderation analysis found no effect of ED history on the relationship between eating behaviours and group. These results suggest that working in the ED field may be a protective factor against developing certain disordered eating behaviours. However, poorer cognitive flexibility may adversely impact EDCRs, and should be considered when carrying out their clinical and/or research duties.

Performing well but not appreciating it - A trait feature of anorexia nervosa

Background

Despite advances in the etiology of anorexia nervosa (AN), a large subgroup of individuals does not profit optimally from treatment. Perfectionism has been found to be a risk factor predicting the onset, severity, and duration of AN episodes. To date, perfectionism has been studied predominantly by the use of self-report questionnaires, a useful approach that may, however, be impacted by demand characteristics, or other distortions of introspective or metacognitive access.

Methods

Here we circumvent these problems via a behavioral paradigm in which participants perform a modified Go/NoGo task, whilst self-evaluating their performance. We compared a group of 33 adolescent females during their first episode of AN (age = 16.0) with 29 female controls (age = 16.2), and 23 adolescent girls recovered from AN (age = 18.3) with 23 female controls (age = 18.5). The controls were closely matched by intelligence quotient and age to the two clinical groups.

Results

First-episode AN and control participants performed equally well on the task (reaction time and errors of commission), whereas the recovered group displayed significantly faster reaction times but incurred the same error rate. Despite performing at least as good as and predominantly better than control groups, both clinical groups evaluated their performances more negatively than controls.

Conclusion

We offer a novel behavioral method for measuring perfectionism independent of self-report, and we provide tentative evidence that this behavioral manifestation of perfectionism is evident during first-episode AN and persists even after recovery.

Unraveling shared susceptibility loci and Mendelian genetic associations linking educational attainment with multiple neuropsychiatric disorders

Background

Empirical studies have demonstrated that educational attainment (EA) is associated with neuropsychiatric disorders (NPDs), suggesting a shared etiological basis between them. However, little is known about the shared genetic mechanisms and causality behind such associations.

Methods

This study explored the shared genetic basis and causal relationships between EA and NPDs using the high-definition likelihood (HDL) method, cross phenotype association study (CPASSOC), transcriptome-wide association study (TWAS), and bidirectional Mendelian randomization (MR) with summary-level data for EA (N = 293,723) and NPDs (N range = 9,725 to 455,258).

Results

Significant genetic correlations between EA and 12 NPDs (rg range - 0.49 to 0.35; all p < 3.85 × 10-3) were observed. CPASSOC identified 37 independent loci shared between EA and NPDs, one of which was novel (rs71351952, mapped gene: ARFGEF2). Functional analyses and TWAS found shared genes were enriched in brain tissue, especially in the cerebellum and highlighted the regulatory role of neuronal signaling, purine nucleotide metabolic process, and cAMP-mediated signaling pathways. CPASSOC and TWAS supported the role of three regions of 6q16.1, 3p21.31, and 17q21.31 might account for the shared causes between EA and NPDs. MR confirmed higher genetically predicted EA lower the risk of ADHD (ORIVW: 0.50; 95% CI: 0.39 to 0.63) and genetically predicted ADHD decreased the risk of EA (Causal effect: -2.8 months; 95% CI: -3.9 to -1.8).

Conclusion

These findings provided evidence of shared genetics and causation between EA and NPDs, advanced our understanding of EA, and implicated potential biological pathways that might underlie both EA and NPDs.

The association between eating disorders and perfectionism in adults: A systematic review and meta-analysis

OBJECTIVE

Dimensions of perfectionism are associated with the onset and maintenance of eating disorder pathology in both clinical and non-clinical samples. The aim of this study was to conduct a systematic review and meta-analysis of the association between perfectionism and eating disorders in adults.

METHOD

A literature search was conducted using the PsycINFO, Medline, Scopus, Embase, Web of Science and ProQuest databases. Ninety-five studies met the inclusion criteria and included a total sample of 32,840 participants (clinical eating disorder diagnosis N = 2414, non-clinical N = 30,428). Correlation coefficients (r) for the association between eating disorders and perfectionism were pooled. A meta-analysis to determine the association between two dimensions of perfectionism and eating disorder symptoms was conducted. Subgroup analyses were conducted with studies using clinical samples, and studies using the Eating Disorder Examination Questionnaire.

RESULTS

The pooled effect size for the association between perfectionistic concerns and eating disorder symptoms was r = 0.33 [0.30, 0.37]; and r = 0.20 [0.14, 0.25] for the association between perfectionistic strivings and eating disorder symptoms. In the clinical subgroup analyses the effect sizes were r = 0.40 [0.22, 0.58]; and r = 0.35 [0.26, 0.44] respectively. Medium to high heterogeneity was identified across all subgroup analyses and a significant level of publication bias was also identified.

DISCUSSION

The findings indicate both perfectionistic strivings and perfectionistic concerns have significant associations with eating disorders, and further support the argument that both dimensions of perfectionism are important factors in the prevention and treatment of eating disorders.

Cognitive and Interpersonal Factors in Adolescent Inpatients with Anorexia Nervosa: A Network Analysis

The cognitive-interpersonal model of anorexia nervosa (AN) posits that cognitive and interpersonal traits contribute to the development and maintenance of AN. We investigated cognitive and interpersonal factors put forward by the model in a sample of 145 adolescent inpatients with AN using network analysis. Our main outcomes included core eating disorder symptoms, cognitive style, socio-affective factors, and mood symptoms. We estimated a cross-sectional network using graphical LASSO. Core and bridge symptoms were identified using strength centrality. Goldbricker was used to reduce topological overlap. The node with the highest strength centrality was Concern over Mistakes, followed by Eating Preoccupation, Social Fear, and Overvaluation of Weight and Shape. The nodes with the highest bridge strength were Concern over Mistakes, Doubt about Actions, Overvaluation of Weight and Shape, and Depression. Notably, both performance on a cognitive flexibility task and BMI were not connected to any other nodes and were subsequently removed from the final network. We provide partial support for the cognitive-interpersonal model while also supporting certain premises put forward by the transdiagnostic cognitive-behavioral model. The high centrality of Concern over Mistakes and Social Fear supports the theory that both cognitive and interpersonal difficulties contribute to AN, particularly in adolescence.

From symptoms to subjective and bodily experiences: the contribution of the Psychodynamic Diagnostic Manual (PDM-2) to diagnosis and treatment monitoring in eating disorders

PURPOSE

Atheoretical and descriptive conceptualizations of eating disorders (EDs) have faced substantial criticism due to their limited ability to assess patients' subjective characteristics and experiences, as needed to determine the most appropriate treatment options. The present article provides an overview of the clinical and empirical literature supporting the potential contribution of the Psychodynamic Diagnostic Manual (PDM-2) to both diagnostic assessment and treatment monitoring.

METHODS

Following a discussion of the most relevant shortcomings of current diagnostic models of EDs and a description of the rationale and structure of the PDM-2, evidence supporting the core PDM-2 dimensions of ED patients' subjective experiences (i.e., affective states, cognitive processes, relational patterns, somatic/bodily experiences and states) are examined, alongside their relevance to ED diagnosis and treatment.

RESULTS

Overall, the reviewed studies support the diagnostic importance of these patterns of subjective experiences in EDs, highlighting their potential role as either predisposing or maintaining factors to target in psychotherapy. A growing body of multidisciplinary evidence also shows that bodily and somatic experiences are central to the diagnosis and clinical management of ED patients. Moreover, there is evidence that a PDM-based assessment may enable closer monitoring of patient progress during treatment, with regard to both subjective experiences and symptom patterns.

CONCLUSIONS

The study suggests that current diagnostic frameworks for EDs would benefit from the addition of a person-centered perspective that considers not only symptoms, but also patients' full range of functioning-including their deep and surface-level emotional, cognitive, interpersonal, and social patterns-to improve patient-tailored interventions.

LEVEL OF EVIDENCE

Level V, narrative review.

Temporal dynamics of cognitive flexibility in adolescents with anorexia nervosa: A high-density EEG study

Impairment in cognitive flexibility is a core symptom of anorexia nervosa (AN) and is associated with treatment resistance. Nevertheless, studies on the neural basis of cognitive flexibility in adolescent AN are rare. This study aimed to investigate brain networks underlying cognitive flexibility in adolescents with AN. To address this aim, participants performed a Dimensional Change Card Sorting task during high-density electroencephalography (EEG) recording. Anxiety was measured with the State-Trait Anxiety Inventory. Data were collected on 22 girls with AN and 23 controls. Evoked responses were investigated using global-spatial analysis. Adolescents with AN showed greater overall accuracy, fewer switch trial errors and reduced inverse efficiency switch cost relative to controls, although these effects disappeared after adjusting for trait and state anxiety. EEG results indicated augmented early visual orienting processing (P100) and subsequent impaired attentional mechanisms to task switching (P300b) in subjects with AN. During task switching, diminished activations in subjects with AN were identified in the posterior cingulate, calcarine sulcus and cerebellum, and task repetitions induced diminished activations in a network involving the medial prefrontal cortex, and several posterior regions, compared with controls. No significant associations were found between measures of cognitive flexibility and anxiety in the AN group. Findings of this study suggest atypical neural mechanisms underlying cognitive flexibility in adolescents with AN. More importantly, our findings suggest that different behavioural profiles in AN could relate to differences in anxiety levels. Future research should investigate the efficacy of cognitive training to rebalance brain networks of cognitive flexibility in AN.

Neural Correlates of Executive Functioning in Anorexia Nervosa and Obsessive-Compulsive Disorder

Anorexia nervosa (AN) and obsessive-compulsive disorder (OCD) are commonly reported to co-occur and present with overlapping symptomatology. Executive functioning difficulties have been implicated in both mental health conditions. However, studies directly comparing these functions in AN and OCD are extremely limited. This review provides a synthesis of behavioral and neuroimaging research examining executive functioning in AN and OCD to bridge this gap in knowledge. We outline the similarities and differences in behavioral and neuroimaging findings between AN and OCD, focusing on set shifting, working memory, response inhibition, and response monitoring. This review aims to facilitate understanding of transdiagnostic correlates of executive functioning and highlights important considerations for future research. We also discuss the importance of examining both behavioral and neural markers when studying transdiagnostic correlates of executive functions.

Can Cognitive Flexibility and Clinical Perfectionism Be Used to Identify People with Anorexia Nervosa?

Poor cognitive flexibility and perfectionism are common features in anorexia nervosa (AN). The current study aimed to investigate cognitive flexibility and clinical perfectionism as potential predictors of AN. Twenty women with a current diagnosis of AN (M age = 28.25, SD = 7.62) and 170 community participants with no lifetime history of an eating disorder (M age = 29.23, SD = 9.88) took part in an online cross-sectional study that included self-report questionnaires of cognitive flexibility and clinical perfectionism. It was found that compared to the community sample, women with AN self-reported significantly poorer cognitive flexibility and significantly greater clinical perfectionism. In a regression model, clinical perfectionism (but not self-reported cognitive flexibility) significantly predicted group membership. The specificity and sensitivity of the model were high. These preliminary findings indicate that clinical perfectionism may represent a key feature of AN and may accurately discriminate between participants with and without AN, though more research is required.

Towards a better understanding of adolescent obsessive-compulsive personality traits and obsessive-compulsive symptoms from growth trajectories of perfectionism

Although there is increasing attention for the interrelationship between obsessive-compulsive personality disorder (OCPD) and obsessive-compulsive disorder (OCD), their shared characteristics in terms of childhood trait antecedents remain understudied. Perfectionism may be a viable candidate trait antecedent, given its role in the clinical manifestation of both OCPD and OCD in adulthood, and the evidence that perfectionism reflects a dispositional tendency observable from childhood onwards. However, little is known about childhood trajectories of perfectionism with prospective links to later OCPD versus OCD. Using latent growth curve modeling, this study explored the baseline and growth of childhood perfectionism in 485 community and referred children (55.5% girls, 7.17-14.78 years old, Mage = 10.74, SD = 1.50) across three waves. Adolescent OCPD traits and OCD symptoms were measured in Wave 4. An overall decreasing trend of perfectionism from childhood through adolescence appeared, without inter-individual differences in growth. Individual differences in baseline levels of childhood perfectionism were significant, and equally predicting adolescent OCPD and OCD outcomes. At a more specific level, childhood perfectionism predicted most strongly the rigid perfectionism component of OCPD, and the orderliness/cleanliness/perfectionism and obsession domain of OCD. This demonstrates the value of childhood perfectionism for understanding differential outcomes of adolescent OCPD traits and OCD symptoms.

Personality disorder traits, obsessive ideation and perfectionism 20 years after adolescent-onset anorexia nervosa: a recovered study

PURPOSE

The many studies examining the relationship between anorexia nervosa (AN) and personality abnormalities have observed high comorbidity. However, no definitive studies to date have established whether there is a causal connection or whether it is a complication. The current study aimed to explore the nature of the relationship between personality disorder (PD) traits, obsessionality and perfectionism, using a study design that allows the testing of some comorbidity models.

METHODS

Twenty-nine women were recruited from a group of former AN patients treated during their adolescence in a specialized unit around 20 years before the time of this study. They were divided into two groups according to the current presence of eating disorder (ED) symptoms (current-ED, n = 11; recovered, n = 18). Both groups were compared to a matched control group (n = 29) regarding current PD traits, obsessive beliefs and perfectionism.

RESULTS

Borderline PD traits, most cluster C PD traits and overestimation of threat were more common in the current-ED group than in the control and recovered groups. Obsessive-compulsive PD traits, intolerance of uncertainty, and perfectionism were also significantly more prevalent in the current-ED group compared to controls but did not reach significance when compared to the recovered group. No significant differences were found between the recovered and control groups.

CONCLUSION

Our results mostly support the personality abnormalities observed as a transient effect related to the presence of ED psychopathology in patients with adolescent-onset AN.

LEVEL OF EVIDENCE

Level III, case-control analytic studies.

Enduring value of perfectionism and maturity fears for predicting eating disorder maintenance over 10-, 20-, and 30-year follow-up

OBJECTIVE

The Eating Disorder Inventory provides a theoretically informed multidimensional assessment of eating disorder symptoms and associated psychological factors widely used to examine the development and maintenance of eating disorders. Yet, mixed findings for some factors raise questions about whether their prognostic value varies as a function of duration of follow-up or type of eating pathology studied.

METHOD

The current study compared prognostic value of perfectionism, maturity fears, and interpersonal distrust as predictors of restrictive versus bulimic symptom patterns at 10-, 20-, and 30-year follow-up in N = 127 individuals diagnosed with eating disorders at baseline. Multivariable regression analyses and statistical comparison of effect sizes were used.

RESULTS

Drive for Thinness at 10- and 30-year follow-up was predicted by higher Perfectionism and higher Maturity Fears at baseline. Baseline Maturity Fears also predicted higher Drive for Thinness at 20-year follow-up and higher Bulimia at 10- and 20-year follow-up. Interpersonal Distrust did not demonstrate prognostic significance in multivariable models. Comparisons of effect sizes support that some differences in statistical significance reflect differences in prognostic value of psychological factors.

DISCUSSION

Both duration of follow-up and type of pathology impact the predictive value of psychological factors and have important implications for understanding illness maintenance. Findings support the utility of targeting Perfectionism for restrictive symptoms. Developing interventions focused on Maturity Fears may provide a novel approach to reducing both restrictive and bulimic symptoms.

Longitudinal relations of self-criticism with disordered eating behaviors and nonsuicidal self-injury

OBJECTIVE

Self-criticism has been proposed as a transdiagnostic predictor of disordered eating and nonsuicidal self-injury (NSSI). First, this study explored cross-sectional associations of multiple disordered eating behaviors, NSSI, and self-criticism. Second, it tested longitudinal relations of self-criticism with disordered eating and NSSI, adjusting for baseline levels of both behaviors.

METHODS

In Sub-study 1, undergraduates (N = 251, 79.5% female, M_age = 19.1 years) completed self-report measures of disordered eating, NSSI, and self-criticism at baseline and after 8 weeks. In Sub-study 2, community-based young adults with histories of disordered eating, NSSI, or both (N = 517, 88.8% female, M_age = 24.7 years) completed measures of disordered eating, NSSI, and self-criticism at baseline and after 4 weeks. All measures were completed online.

RESULTS

In Sub-study 1, both disordered eating and NSSI showed significant cross-sectional associations with self-criticism, and self-criticism was significantly related to binge eating, fasting, and NSSI at follow-up. In Sub-study 2, both behaviors again showed significant cross-sectional associations with self-criticism. Self-criticism showed significant longitudinal relations with fasting, purging, and excessive exercise. Longitudinal relations of self-criticism with NSSI varied across disordered eating behaviors.

DISCUSSION

NSSI showed cross-sectional associations with a range of disordered eating behaviors. Self-criticism reflects a common correlate of both disordered eating and NSSI. Evidence supported transdiagnostic longitudinal impact of self-criticism across multiple forms of disordered eating but provided more limited support for impacts on NSSI.

Perfectionism in Eating Disorders: Are Long-Term Outcomes Influenced by Extent and Changeability in Initial Perfectionism?

Purpose

Perfectionism has been found to predict outcomes in the treatment of eating disorders (ED). In the present study, we took advantage of longitudinal data to: a) investigate whether there are different patterns of perfectionism during the first six months after admission in a clinical sample of patients with ED, and b) describe how these patterns are related to long-term outcome.

Methods

A sample of patients (N=294) from the Coordinated Evaluation and Research at Specialized Units for Eating Disorders database was divided into clusters according to perfectionism patterns measured with the EDI-2 perfectionism scale at baseline, and six months in treatment. Cluster analysis was performed on the extent and perseverance/changeability of self-oriented and socially described perfectionism. Outcome was measured with the EDI-2 and the SCL-63. Frequencies of eating disorder diagnoses were investigated.

Results

Five clusters were identified. Low perfectionism was associated with lower levels of ED and psychiatric symptomatology at baseline. There were no significant differences between clusters on outcome variables at 36-month follow-up.

Conclusions

Results indicated better psychiatric and psychological health three years after the initial measure. Patterns of relations between the extent and possible changes of perfectionism, measured with the EDI-P at baseline and after six months, did not appear to be associated with long-term outcomes on psychiatric health ratings.

Differences in set-shifting and central coherence across anorexia nervosa subtypes in children and adolescents

OBJECTIVE

Regarding executive functioning in anorexia nervosa (AN), little is known about differences between the restricting (AN-R) and binge eating/purging (AN-BP) subtypes. Especially for adolescents, there is sparse data. Hence, the current aim is to investigate differences in set-shifting, central coherence, and self-reported executive functioning across adolescent AN subtypes.

METHODS

Ninety AN-R, 21 AN-BP, and 63 controls completed an extensive assessment battery including neuropsychological tests for executive functioning and the self-report questionnaire Behavior Rating Inventory of Executive Functioning.

RESULTS

Patients with AN-R and AN-BP did not differ on neuropsychological measures, and both performed similarly to controls. Behavior Rating Inventory of Executive Functioning scores fell within the normal range with AN subtypes showing mostly comparable ratings. AN-BP patients scored higher on 2 composite indices and the "shift" subscale compared with AN-R.

CONCLUSIONS

The results suggest similar cognitive functioning in adolescent AN subtypes as well as healthy controls. However, more research is needed to draw more general conclusions.

Adolescent perfectionism: Structural features of the Frost Multidimensional Perfectionism Scale and correlates with attachment and psychopathology

OBJECTIVES

Perfectionism is recognized as a significant risk factor for psychopathology. Emerging research links attachment to perfectionism in adult and college-age samples. The Frost Multidimensional Perfectionism Scale (FMPS) has been used in adults and adolescents with a variety of factor structures found. This study sought to establish the factor structure in a general adolescent sample prior to testing for associations between perfectionism, attachment, and psychopathology in the same sample.

DESIGN

A cross-sectional survey design was used. Confirmatory factor analysis, and correlational and regression analyses were employed.

METHODS

A total of 290 adolescents, aged 12-18 years, were recruited from a state secondary school. All completed the FMPS along with brief measures of attachment and psychopathology.

RESULT

Exploratory and confirmatory factor analyses failed to replicate previously published models, and a new six-item, 1-factor model representing perfectionism was found instead. This new variable was then used to establish a role for perfectionism and attachment anxiety in predicting internalizing problems. Perfectionism also correlated with conduct problems and hyperactivity.

CONCLUSION

This study established a novel factor structure for the FMPS, allowing proof of principle of the role of perfectionism in a relationship with attachment and psychopathology, which after replication, may inform new interventions for perfectionism. Caution is noted about the use of extant perfectionism measures that are not properly developmentally informed and which do not capture the dynamic nature of adolescence and adolescent perfectionism.

PRACTITIONER POINTS

Perfectionism is a feature of adolescent psychopathology, including internalizing and externalizing problems. Perfectionism is associated with attachment anxiety and together contributes to internalizing problems. Current conceptualizations of perfectionism may not capture the specific developmental and dynamic aspects of adolescence and should not be regarded as a stable personality trait.

Identifying Predictors Associated with the Severity of Eating Concerns in Females with Eating Disorders

Considering how to improve efficacy of therapeutic strategies, the overall objective of the present study was to investigate the extent of eating concerns and to identify predictors associated with the severity of disordered eating symptomatology among people with eating pathologies. We screened 80 female eating disordered patients, ranging from 13 to 40 years, by means of self-report measures of parental behavior as perceived by the offspring, self-esteem, perfectionism, body shame and eating disorder severity. Self-reported weight and height were obtained. The diagnosis of bulimia nervosa resulted to be associated with a greater severity of the eating symptomatology. Maladaptive perfectionism, body shame and self-esteem, significantly predicted the level of eating concerns. The recognition of potential maintaining factors may support the choice of particular therapeutic strategies to improve the treatment of eating pathologies and their outcomes.

Long-term follow up of hospitalized pediatric anorexia nervosa restricting type

BACKGROUND

Information on long-term follow up of childhood-onset anorexia nervosa is scarce. This study investigated long-term (>10 years) course, outcome and prognostic factors for hospitalized childhood-onset anorexia nervosa restricting type (ANR).

METHODS

Forty-one ANR girls admitted to a single regional center participated. Median age at first admission was 13.3 years (range, 8.6-15.6 years). The longitudinal clinical course was retrospectively determined for a median follow-up period of 17.1 years (range, 10.4-21.1 years). We analyzed physical, psychological, and social variables to predict partial remission (PR) and full remission (FR).

RESULTS

The completion rate of follow up >10 years was high at 97%. At final evaluation (n = 38), distribution of prognosis was as follows: FR, n = 27 (71%); PR, n = 6 (16%); and non-remission, n = 5 (13%). The cumulative ratio of PR and FR increased during the first 5-6 years, and gradually reached a plateau at around 10 years. More than 10 years after the onset, one patient eventually achieved FR, and one patient died. Seven patients were rehospitalized and two died due to suicide during the entire follow up. On multivariate analysis, family disorders/problems rating score was a significant predictor of PR and FR.

CONCLUSIONS

This study included hospitalized ANR children aged ≤15 years, the youngest cohort ever reported. Long-term prognosis is generally favorable, but the mortality rate was 5%. Careful long-term follow up >10 years is needed to evaluate outcome of childhood-onset ANR, and family therapy is important in high-risk patients with family disorders/problems.

Family relations in eating disorders: the Genogram as instrument of assessment

The present study aimed to evaluate the transactional patterns in families of women with EDs, through the use of the Genogram. The study included 12 girls and women linked to a multidisciplinary service. For the preparation of Genograms, a semistructured interview script was built that included specific topics regarding family relationships. Genograms´ analysis followed the recommendations professed by the specialized literature. It was evident that families presented few skills in managing stressful events and resolving conflicts, resulting in emotional distance between members and vulnerability of bonds. The Genogram was proved useful as a resource for research and evaluation in the area of EDs, and the generated data was convergent with the literature. Results provide important subsidies for health professionals, since they indicate the need for care and development of therapeutic alliance with the family in the treatment for EDs.

A Sisyphean task: experiences of perfectionism in patients with eating disorders

BACKGROUND

Despite the theoretical links between eating disorders and perfectionism, the definition of perfectionism in practice is complicated. The present study explored descriptions and experiences of perfectionism described by a transdiagnostic sample of patients.

METHODS

In-depth, semi-structured interviews were carried out with 15 patients. The interviews were analyzed by Thematic Analysis. A comparison between the patients' scorings on the Eating Disorder Inventory-Perfectionism scale was also performed.

RESULTS

Seven themes were found: The origins of perfectionism, Top performance, Order and self-control, A perfect body, Looking good in the eyes of others, A double-edged coping strategy, and A Sisyphean task. The women in this study did not emphasize weight and body as the main perfectionistic strivings. Core descriptions were instead order, self-control and top performances. All of the participants described the awareness of reaching perfectionism as impossible. Scorings of self-oriented perfectionism was significantly higher compared to socially prescribed perfectionism. No differences in the narratives related to perfectionism scores or eating disorder diagnoses were found.

CONCLUSIONS

The results showed that psychometric measures do not always capture the patients' definitions of perfectionism, but regarding that perfectionism serves as a means to regulate affects and may lead into an exacerbation of the eating disorder, and the development of obsessive-compulsive symptoms, it is important to investigate the personal definitions of perfectionism.

Relacionamentos Afetivo-Familiares em Mulheres com Anorexia e Bulimia

RESUMO Este estudo teve por objetivo investigar a rede social de apoio de mulheres com anorexia e bulimia, com ênfase em suas relações afetivo-familiares. A amostra foi composta por 12 participantes atendidas em hospital universitário. Os instrumentos utilizados foram: roteiro de entrevista semiestruturada, Mapa de Rede e Genograma. Os resultados indicaram que as redes sociais das participantes têm configuração restrita, com proeminência de membros da família em sua composição. Os relacionamentos familiares oscilam, contudo, entre turbulência e distanciamento afetivo. As relações de afeto mantidas com pais, cônjuges e namorados são marcadas por divergências e insatisfações. A baixa densidade da rede de amizades e o empobrecimento da vida social resultam em isolamento e dificuldades de dar início e/ou manter relacionamentos afetivos duradouros.

Obsessive-compulsivity and working memory are associated with differential prefrontal cortex and insula activation in adolescents with a recent diagnosis of an eating disorder

The role of rumination at the beginning of eating disorder (ED) is not well understood. We hypothesised that impulsivity, rumination and restriction could be associated with neural activity in response to food stimuli in young individuals with eating disorders (ED). We measured neural responses with functional magnetic resonance imaging (fMRI), tested working memory (WM) and administered the eating disorders examination questionnaire (EDE-Q), Barratt impulsivity scale (BIS-11) and obsessive-compulsive inventory (OCI-R) in 15 adolescent females with eating disorder not otherwise specified (EDNOS) (mean age 15 years) and 20 age-matched healthy control females. We found that EDNOS subjects had significantly higher scores on the BIS 11, EDE-Q and OCI-R scales. Significantly increased neural responses to food images in the EDNOS group were observed in the prefrontal circuitry. OCI-R scores in the EDNOS group also significantly correlated with activity in the prefrontal circuitry and the cerebellum. Significantly slower WM responses negatively correlated with bilateral superior frontal gyrus activity in the EDNOS group. We conclude that ruminations, linked to WM, are present in adolescent females newly diagnosed with EDNOS. These may be risk factors for the development of an eating disorder and may be detectable before disease onset.

Review: Assessment, development, and treatment of childhood perfectionism: a systematic review

BACKGROUND

In the adult literature, perfectionism has been linked with psychopathology and poor treatment outcomes, leading to perfectionism-focussed therapies. The child and adolescent perfectionism literature is comparatively sparse.

METHOD

A systematic search of five electronic databases (Web of Knowledge, APA PsycNET, PubMed, ERIC/ProQuest, and Scopus) was conducted to identify studies of perfectionism in children and adolescents, in the context of psychopathology.

RESULTS

The search identified 133 studies, 84 of which discussed perfectionism as a correlate of mental health problems. These studies were briefly synthesised, with the systematic review focussing on evaluating papers on the development (n = 23), assessment (n = 19), and treatment (n = 7) of perfectionism.

CONCLUSION

Treatment studies did not reflect the phenomenology of perfectionism found in this review.

Perfectionistic cognitions and eating disturbance: distinct mediational models for males and females

OBJECTIVE

Perfectionism has long been known to correlate with eating disturbance (ED). One mechanism through which this personality tendency may lead to ED is through increasing one's daily perfectionistic thoughts. This study examined the mediating role of perfectionistic thinking in the personality perfectionism-ED relationship among both male and female college students, and included measures assessing both typically-male and typically-female ED symptoms.

METHOD

A majority-White sample of 140 males and 329 females completed online versions of the Multidimensional Perfectionism Scale (Hewitt & Flett, 1991), Perfectionism Cognitions Inventory (Flett, Hewitt, Blankstein, & Gray, 1998), Drive for Muscularity Scale (McCreary, Sasse, Saucier, & Dorsch, 2004), items from the Eating Disorder Examination Questionnaire (Fairburn, 2008), and other measures. Regression tests examined the hypothesized role of perfectionistic cognitions as a mediator, including participant age, BMI, and positive and negative affect as covariates.

RESULTS

Among women, relationships between both self-oriented (Sobel's statistic=-4.63, p<.001) and socially prescribed perfectionism (Sobel's statistic=-5.77, p<.001) and dieting behavior were fully mediated by increased perfectionistic thinking. Among men, however, the relationship between only self-oriented perfectionism and bulimic (but not dieting) behavior, was fully mediated by increased perfectionistic thinking (Sobel's statistic=-2.53, p=.01).

CONCLUSIONS

Perfectionistic cognitions play an important linking role between personality perfectionism and ED, and can illuminate important differences by gender in eating disturbance. Such findings can improve validity of ED assessment in both genders, and provide a clear pathway to interventions to decrease ED in both genders.

Personality Assessment Inventory profiles of university students with eating disorders

BACKGROUND

Eating disorders are complex disorders that involve medical and psychological symptoms. Understanding the psychological factors associated with different eating disorders is important for assessment, diagnosis, and treatment.

METHODS

This study sought to determine on which of the 22 Personality Assessment Inventory (PAI) scales patients with anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified (EDNOS) differed, and whether the PAI can be used to classify eating disorder subtypes. Because we were interested in both whether the PAI could be used to differentiate eating disorder subtypes from each other, as well as from other disorders, we also included a group of patients with major depression.

RESULTS

The three eating disorder groups did differ significantly from each other, and from the patients with depression, on a number of the PAI scales. Only two PAI scales (Anxiety and Depression), however, exceeded a T-score of 70 for the patients with anorexia nervosa, no scales exceeded a T-score of 70 for the patients with bulimia nervosa or EDNOS, and only two exceeded a T-score of 70 for the patients with depression (Depression and Suicide). A discriminant function analysis revealed an overall correct classification between the groups of 81.6%.

CONCLUSIONS

The PAI helps to understand the psychological factors associated with eating disorders and can be used to assist with assessment. Continued investigation using the PAI in an eating disordered population is supported.

Developmental trajectories of maladaptive perfectionism among African American adolescents

This study examined the developmental trajectories of maladaptive perfectionism over a 7-year period among African American youth living in an urban setting (N = 547). In particular, the study attempted to determine whether two maladaptive aspects of perfectionism (socially prescribed and self-critical) changed over time and could be distinguished by variables in 6th and 12th grades (Mage at study entry [first grade] was 6.22 years [SD = 0.34]). Four classes best described the developmental trajectories on both measures of maladaptive perfectionism: high, low, increasing, and decreasing. Sixth- and 12th-grade correlates, including measures of internalizing symptoms, mostly confirmed the distinctiveness of these classes. Parallel process analyses suggested that the two processes are complementary, yet distinct. Implications regarding the prevention of maladaptive perfectionism are discussed.

Nothing tastes as good as skinny feels: the neurobiology of anorexia nervosa

Individuals with anorexia nervosa (AN) engage in relentless restrictive eating and often become severely emaciated. Because there are no proven treatments, AN has high rates of relapse, chronicity, and death. Those with AN tend to have childhood temperament and personality traits, such as anxiety, obsessions, and perfectionism, which may reflect neurobiological risk factors for developing AN. Restricted eating may be a means of reducing negative mood caused by skewed interactions between serotonin aversive or inhibitory and dopamine reward systems. Brain imaging studies suggest that altered eating is a consequence of dysregulated reward and/or awareness of homeostatic needs, perhaps related to enhanced executive ability to inhibit incentive motivational drives. An understanding of the neurobiology of this disorder is likely to be important for developing more effective treatments.

An examination of early childhood perfectionism across anorexia nervosa subtypes

OBJECTIVE

To examine childhood perfectionism in anorexia nervosa (AN) restricting (RAN), purging (PAN), and binge eating with or without purging (BAN) subtypes.

METHOD

The EATATE, a retrospective assessment of childhood perfectionism, and the eating disorder inventory (EDI-2) were administered to 728 AN participants.

RESULTS

EATATE responses revealed general childhood perfectionism, 22.3% of 333 with RAN, 29.2% of 220 with PAN, and 24.8% of 116 with BAN; school work perfectionism, 31.2% with RAN, 30.4% with PAN, and 24.8% with BAN; childhood order and symmetry, 18.7% with RAN, 21.7% with PAN, and 17.8% with BAN; and global childhood rigidity, 42.6% with RAN, 48.3% with PAN and 48.1% with BAN. Perfectionism preceded the onset of AN in all subtypes. Significant associations between EDI-2 drive for thinness and body dissatisfaction were present with four EATATE subscales.

DISCUSSION

Global childhood rigidity was the predominate feature that preceded all AN subtypes. This may be a risk factor for AN.

Is there a perfectionist in each of us? An experimental study on perfectionism and eating disorder symptoms

Previous studies have shown consistent associations between perfectionism and eating disorder (ED) symptoms. However, to date, only one study (Shafran et al., 2006) used an experimental design to examine in a non-clinical sample the causal relationship between perfectionism and ED symptoms. The current experimental study aimed to build on that study by examining the role of trait perfectionism in the effects of an experimental induction of perfectionism and by adopting a multidimensional approach to perfectionism. University students (N=100; Mage=20.6 years; SD=2.24) were randomly assigned to one of three experimental conditions, that is, a high Personal Standards condition, a condition combining Personal Standards perfectionism and Evaluative Concerns perfectionism, and a non-perfectionist condition. Compared to the non-perfectionist condition, participants in the two perfectionist conditions reported higher levels of state perfectionism during the next 24 h and this effect occurred irrespective of trait perfectionism levels. Further, participants in the perfectionist conditions, compared to those in the non-perfectionist condition, reported significantly higher levels of restraint and binging during the 24 h after manipulation. Together, the results suggest that perfectionism can be induced in people irrespective of their levels of trait perfectionism and that perfectionism represents a causal risk factor for ED pathology.

Perfectionism dimensions in major postpartum depression

BACKGROUND

Although perfectionism from a multidimensional perspective has generally been associated with depressive illness, there are not many studies on its role in major depression in the postnatal period. The aim of the present study was to explore the relationship between perfectionism dimensions using the Frost Multidimensional Perfectionism Scale (FMPS) and major postpartum depression.

METHODS

One-hundred-twenty-two women with major postpartum depression (SCID-I; DSM-IV) and 115 healthy postpartum women were evaluated using the FMPS, an instrument for the assessment of six perfectionism dimensions: concern over mistakes, personal standards, parental expectations, parental criticism, doubt about actions and organisation. Other variables were also considered: neuroticism, psychiatric history, social support, life events and genotype combinations according to serotonin transporter expression (5-HTTLPR and Stin2 VNTR polymorphisms).

RESULTS

The prevalence of high-perfectionism was higher in major postpartum depression group than in control group (34% vs. 11%; p<0.001). Multivariate models confirmed high-perfectionism as an independent factor associated with major postpartum depression. Specifically, the high-concern over mistakes dimension increased over four-fold the odds of major depression in postpartum period. (OR=4.14; 95% CI=1.24-13.81) Neuroticism, personal psychiatric history and 5-HTT low-expressing genotypes at one of the loci were also identified as independent factors.

CONCLUSIONS

High-perfectionism, and particularly high-concern over mistakes is a personality dimension associated with major postpartum depression. The inclusion of perfectionism assessment, together with others factors, may be considered in order to improve the detection of women at risk of postpartum depression, in whom early intervention may be of benefit.

Altered implicit category learning in anorexia nervosa

OBJECTIVE

Recent research has identified specific cognitive deficits in patients with anorexia nervosa (AN), including impairment in executive functioning and attention. Another such cognitive process, implicit category learning has been less studied in AN. This study examined whether implicit category learning is impaired in AN.

METHOD

Twenty-one women diagnosed with AN and 19 control women (CW) were administered an implicit category learning task in which they were asked to categorize simple perceptual stimuli (Gabor patches) into one of two categories. Category membership was based on a linear integration (i.e., an implicit task) of two stimulus dimensions (orientation and spatial frequency of the stimulus).

RESULTS

AN individuals were less accurate on implicit category learning relative to age-matched CW. Model-based analyses indicated that, even when AN individuals used the appropriate (i.e., implicit) strategy they were still impaired relative to CW who also used the same strategy. In addition, task performance in AN patients was worse the higher they were in self-reported novelty seeking and the lower they were in sensitivity to punishment.

CONCLUSIONS

These results indicate that AN patients have implicit category learning deficits, and given this type of learning is thought to be mediated by striatal dopamine pathways, AN patients may have deficits in these neural systems. The finding of significant correlations with novelty seeking and sensitivity to punishment suggests that feedback sensitivity is related to implicit learning in AN.

Incorporating dispositional traits into the treatment of anorexia nervosa

We provide a general framework to guide the development of interventions that aim to address persistent features in eating disorders that may preclude effective treatment. Using perfectionism as an exemplar, we draw from research in cognitive neuroscience regarding attention and reinforcement learning, from learning theory and social psychology regarding vicarious learning and implications for the role modeling of significant others, and from clinical psychology on the importance of verbal narratives as barriers that may influence expectations and shape reinforcement schedules.

Imagem corporal e comportamentos de risco para transtornos alimentares em bailarinos profissionais

INTRODUÇÃO E OBJETIVO: A grande preocupação com a aparência e a forma física e a constante pressão para manterem baixo peso corporal são fatores que levam a distorções da imagem corporal e tornam os bailarinos um grupo de risco para o desenvolvimento de transtornos alimentares (TA). O objetivo deste estudo foi avaliar a percepção da imagem corporal e sua associação com comportamentos de risco para TA em bailarinos profissionais. MÉTODOS: Foram estudados 61 bailarinos (39 mulheres e 22 homens) de uma instituição representante da elite do balé clássico brasileiro. A avaliação dos comportamentos de risco para TA foi feita com base nas versões em português dos questionários Eating Attitudes Test (EAT-26) e Bulimic Investigatory Test Edinburgh (BITE). A Escala de Silhuetas de Stunkard foi utilizada para avaliação da percepção da imagem corporal. A associação entre as variáveis foi avaliada com base na razão de prevalência (RP) e seus respectivos intervalos de confiança (IC) de 95%. RESULTADOS: Trinta e um bailarinos (50,8%) gostariam de ter a silhueta menor que a autopercebida como usual. A presença de comportamentos de risco para TA foi 2,71 vezes maior (IC 95% = 1,02 - 7,18) entre os que desejavam ter silhueta menor que a usual e 2,64 vezes maior (IC 95% = 1,20 - 5,80) entre aqueles que desejavam ter silhueta menor que a considerada mais saudável, quando comparados com os que estavam satisfeitos com a sua silhueta. CONCLUSÃO: A alta frequência de insatisfação com o corpo encontrada pode estar colaborando para ocorrência de comportamentos de risco para TA nos bailarinos investigados.

Psychopathology in underweight and weight-recovered females with anorexia nervosa

OBJECTIVE

To compare general and eating disorder-specific psychopathology in patients with acute anorexia nervosa (acAN), weight-recovered patients (recAN) and healthy control women (HCW).

METHODS

One hundred anorexia nervosa patients (66 acAN and 34 recAN) and 88 HCW were included in our study. Psychopathology was assessed by self-report questionnaires [Symptom Check List 90 Revised (SCL-90-R), Eating Disorder Inventory-2 (EDI- 2)] as well as by interview [Structured Interview of Anorexia Nervosa and Bulimic Syndromes (SIAB-EX)] and compared using multivariate analysis of variance. Plasma leptin levels were determined using enzyme linked immunosorbent assay.

RESULTS

Mean comparisons indicated highly significant differences between acAN and recAN subjects on all psychopatholgy variables, except for perfectionism. RecAN subjects did not differ from HCW. Partial weight recovery was associated with decreasing levels of psychopathology. Correlational analyses suggested strong negative associations between leptin levels and psychopathology.

CONCLUSION

Prolonged malnutrition, as indicated by suppressed plasma leptin levels, is strongly related to eating disorder-specific as well as general psychopathological symptoms. Weight recovery is associated with the absence of psychopathology. These data emphasize the interaction between somatic and psychological variables.