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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  • http://healthforhumans.blogspot.com Murfomurf

    Loved this post! Some sense in a sea of feminism and blaming skinny models & TV!
    I was a researcher in eating disorders for more than a decade and worked with a psychiatrist who believed perfectionism was the root of anorexia nervosa, although now he admits there are other factors just as important. From interviewing several thousand anorexia and bulimia sufferers my opinion is that they have formed a sense of their own identity that is either weak (they don’t really know what sort of person they are) or is very negative- based on some inherited and other environmental contributors to personality, eg tendency to depression, low self-esteem, and inability to assimilate positive attributions about aspects of themselves- eg. praise for academic excellence or ballet performance. I think it can go back to the circumstances in which they were conceived in some cases! Some kids were definitely unwanted and one or both parents gave them minimum attention. No wonder they have an underlying sense of self-loathing, not just for their bodies. Others were made the target of relationship difficulties- they missed out when a partner “sinned” against the “rules of engagement”. Others have been reared by parents who seem to have no idea of how to help kids develop- they expect kids to respond to reason as soon as they can talk and set about undermining them for the rest of their lives. What makes the kids choose eating as a way of expressing their difficulties has almost as many explanations as there are cases I think! There are plenty of anorexic girls with eating disordered mothers and grandmothers I’ve noted and few with anorexic fathers- but there are some. The driven athletes think they can control their lives and performance by concentrating on food and blaming it for any “imperfections”- so they diet and control more when they don’t win. Quite a few athletes I saw who were champion swimmers had been sexually touched or approached by male coaches- it was quite widespread. The old “black sheep of the family” seemed to happen a lot- the parents seem to have almost encouraged one kid to be the sick one, while everyone else had a great life- even where the anorexia sufferer was an identical twin! Of course 99% of the parental contributions could never be broached as they were unconscious and there is no point in blaming one, when the child has to be the one to recover and learn how to cope in any adverse circumstance. It was absolutely marvellous when some rather naughty bulimic girls seemed to suddenly “grow up” emotionally and decide they just weren’t going to keep up the ridiculous habits they had got into. Some got better with help, others just slogged it out alone and made great progress! They were the ones who had one psychiatric appointment for an assessment, insisted there was nothing wrong with them and went away for a few years to have a think. They sometimes stop me in public places and tell me how well they have done!.This is quite heartening to me as a researcher, rather than a clinician!

  • http://www.brightonyourhealth.com Mary Brighton, MS, RD

    Very interesting article. I have heard of this possible link before with AN and perfectionism plus the possible push too of higher intelligence adding another component to increased risk of getting AN.
    As a mother of 3 young girls, including my oldest, 11 years old, who is a strong perfectionist and as her doctor says also ‘highly intelligent’ I am keenly aware of her “predisposition” to developing AN. As a registered dietititan with training in counseling patients with AN, I also see the influence in children with AN of the mother’s (father’s too) unbalanced dietary habits and unhealthy body awareness as another link to their children developing AN.
    Knowing my daughter’s personality, we try to be careful with our outlook on food and body image, especially as a mother. I strive in myself to show my children a balanced healthy and normal outlook in these 2 areas. I know that I am a role model for my children especially in these areas for my 3 girls (and in my son too :) ).
    Food is what it is, just food-never forced to eat it. No comments like “this will make me fat..etc..” Discussion of acceptance of every person’s body whatever size and shape it is. Rarely do I weigh myself and if I do , never in the front of my children.
    I’ve seen too many cases of AN not to be “worried” that one of my children could develop this. Understanding more of the personality traits that tie into to developing AN and having a “normal” outlook on food and body image for our children can hopefully prevent this happening.
    Mary Brighton