Temperament of perfectionism in anorexia nervosa

Temperament is generally defined as innate early emotional and behavioral characteristics that precede puberty and adult development.  Felt to have significant genetic components, temperament is also potentially influenced by environmental factors.

There are a variety of temperament domains that have received significant attention in childhood, adolescent and adult populations.

Some of the most commonly studied domains include:

  • neuroticism
  • harm avoidance
  • novelty seeking
  • reward dependence
  • perfectionism (subdomains have included: concern about mistakes, personal standards, doubts about actions, organization

The temperament of perfectionism has been noted to be elevated in clinical samples of women with anorexia nervosa (AN).  AN has been conceptualized as an overvalued importance of being in control over eating and weight.  Control is a key element of perfectionism as it relates to reducing risk of mistakes and maintaining organization).  Previous studies looking at perfectionism in AN have had limited potential to understand the direction of the relationship between temperament and the diagnosis of AN.  Perfectionism could develop after the illness in response to weight loss or other factors.

Wade, et al. published a study using the Australian twin registry that helps address the issue of direction of effect as well as the potential mechanism for perfectionism to increased AN risk.  In this study, the classic twin genetic methodology was used.  Perfectionism was evaluated as a risk factor along with a variety of of other temperament domains.  The key findings from the study included:

  • Anorexia nervosa subjects showed increased concerns about personal standards, making mistakes and doubts about actions
  • Anorexia nervosa temperament factors linked to genetic mechanism include perfectionism subdomain of personal standards

Significant argument had occurred about how perfectionism might be involved in contributing to risk of AN.  High standards typically has been considered a benign component of perfectionism.  But experimental studies that manipulated personal standards in nonclinical populations have shown this to lead to increases in dietary restraint and regret after eating.  The authors conclude: “Results of the current study would suggest that it is the setting of high standards and goals, rather than self-criticism when goals are not obtained that predisposes people to AN.”  Perfectionism acts as risk factor for AN only in presence of other risk factors (i.e. low self-esteem, body dissatisfaction).

So setting high personal standards (i.e. academic goals, athletic achievement,  low body weight) is not independently a problem.  But when high personal standards are accompanied by other psychological vulnerabilities, problems can develop.  Personal standards can be benign (and productive in many ways) but they can not be considered benign for all.

Better understanding of the personal standards temperament (and cofactors for dysfunctional behavior) that precede AN may provide pathways for prevention as well as treatment.

William Yates is a family physician who blogs at Brain Posts.

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