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Dr Nicholas Hawkes

Perfectionism and Eating Disorders

19 May 2017 | by Nicholas Hawkes

Last week the Faculty for Eating Disorders was pleased to host a workshop by Professor Roz Shafran, a highly respected voice in the field of CBT and implementation science, on the links between perfectionism and eating disorders. As a follow-up, Dr Nick Hawkes (who helped to arrange and organise the event), has been kind enough to provide us with some added background information about the ongoing developments in this area.

At first glance the link between perfectionism and eating disorders is obvious. 

From the degree of calorie restriction to the amount of exercise, from the discipline to follow dietary rules to the frequency of weight checks, and the care taken to count each and every calorie – in all efforts, it is never enough.

However, obvious or not, it is important to be aware that our understanding of perfectionism and eating disorders is based on a series of important steps.

First it was necessary to separate out "clinical perfectionism" (an unhealthy overvaluation of striving that causes serious distress and problems) from a wide range of other attitudes and behaviours (both healthy and unhealthy) that had come to be subsumed into the ever-expanding concept of "perfectionism" as a general term.

Then it was necessary to measure it and understand its links to different clinical disorders, leading to the eventual development of a CBT intervention, tested from case series to controlled trials.

A key turning point came when CBT for bulimia was developed into an effective transdiagnostic approach across the eating disorders, CBT-E, taking into account the common ‘overvaluation’ of eating, weight, and shape (and the control of those things).

This core is maintained by a range of factors, like petals on a vicious flower - too many overly-strict dietary rules, leading to undereating, and the cognitive inflexibility and obsessionality which semi-starvation brings, all combined with a panoply of checking, comparing, and avoidance behaviours, driven by an underlying fear and preoccupation.  And, perhaps just as important is the way in which other aspects of self and life are eroded and pushed aside, leading to a steady decline in function and quality of life.

Many people benefit from CBT-E, but in an effort to understand how to improve outcomes the Oxford group of researchers looked closely at what other issues were common amongst people who found it hardest to make headway against their eating disorders. 

Serious difficulties in managing emotions, interpersonal problems and severe low self-esteem were identified, alongside issues of clinical perfectionism.  Thus CBT-E developed into two forms - focused and ‘broad’ - the latter incorporating treatment of these associated factors. 

Fascinatingly people who had these additional problems did better with the broad CBT-E, whilst people who didn’t responded better to the focused form.  It is surprisingly rare, and very interesting, to find such a different response to different treatments by different groups of people who meet diagnostic criteria for the same disorders.

In my experience there were two main steps which were key to improving our understanding of clinical perfectionism.

  • The first was identifying the parallel between overvaluation of striving and overvaluation of eating, weight and shape.  Each has its appeal and makes sense in the dominant cultures we live in.  Each has its function, they ‘work’ up to a point, until they don’t.  It’s not ‘wrong’ or even unusual to attach value to weight control, or to high personal standards.  Rather the problem is the domination of these things over a person’s life, the extremity of the rules and behaviours which become counterproductive - represented in therapy in the form of a ‘pie chart’ almost completely filled with either weight control or striving, at the expense of friendships, interests, family and so on.

After that the formulation of clinical perfectionism is a veritable mirror of eating disorders – too many too strict rules, unhelpful an unfair comparisons, excessive checking, etc.

  • The second was accepting that shifting perfectionism was not a matter of discussion in the therapy room, but hangs on behaviour changes, such as approaching life for one week with a rigid rule, followed by one week with a guideline, to find out which worked out better, or an experiment involving allowing a minor error so as to find out how much people notice or care.

Ultimately although change can be frightening, and it is often easier for clients and therapists to think and to talk without risking it, there is so much joy and freedom to be gained outside of the tyrannical internal regimes of clinical perfectionism, and we are looking forward to exploring these new empirically grounded approaches in more depth.

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