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Am J Psychiatry 157:11, November 2000 1799
Article
Perfectionism in Anorexia Nervosa:
Variation by Clinical Subtype, Obsessionality,
and Pathological Eating Behavior
Katherine A. Halmi, M.D.
Suzanne R. Sunday, Ph.D.
Michael Strober, Ph.D.
Alan Kaplan, M.D.
D. Blake Wood sid e, Ph.D.
Manfred Fichter, M.D.
Janet Treasure, M.D.
Wade H. Berrettini, M.D.
Walter H. Kaye, M.D.
Objective: The purpose of this study was
to examine the role of perfectionism as a
phenotypic trait in anorexia nervosa and
its relevance across clinical subtypes of
this illness.
Method: The Multidimensional Perfec-
tionism Scale and the perfectionism sub-
scale of the Eating Disorder Inventory
were administered to 322 women with a
history of anorexia nervosa who were par-
ticipating in an international, multicenter
genetic study of anorexia nervosa. All par-
ticipants were additionally interviewed
with the Yale-Brown Obsessive Compul-
sive Scale and the Yale-Brown-Cornell Eat-
ing Disorder Scale. Mean differences on
dependent measures among women with
anorexia nervosa and comparison sub-
jects were examined by using generalized
estimating equations.
Results: Persons who had had anorexia
nervosa had significantly higher total
scores on the Multidimensional Perfec-
tionism Scale than did the healthy com-
parison subjects. In addition, scores of the
anorexia subjects on the Eating Disorder
Inventory-2 perfectionism subscale ex-
ceeded Eating Disorder Inventory-2 nor-
mative data. For the anorexia nervosa
participants, the total score on the Multi-
dimensional Perfectionism Scale and the
Eating Disorder Inventory-2 perfectionism
subscale score were highly correlated.
Total score on the Multidimensional Per-
fectionism Scale was also significantly
related to the total score and the motiva-
tion-for-change subscale score of the Yale-
Brown-Cornell Eating Disorder Scale.
Conclusions: These data show that per-
fectionism is a robust, discriminating
characteristic of anorexia nervosa. Perfec-
tionism is likely to be one of a cluster of
phenotypic trait variables associated with
a genetic diathesis for anorexia nervosa.
(Am J Psychiatry 2000; 157:1799–1805)
What’s come to perfection, perishes.
——R. Browning: Old Pictures in Florence, Stanza 17
This concept of perfectionism by Robert Browning may
be most apt for those with anorexia nervosa. A unidimen-
sional definition of perfectionism is “the belief that a
perfect state exists that one should try to attain” (1). Over
a century ago, Louis-Victor Marcé commented on the ob-
stinate refusal of food of persons with anorexia nervosa
(2). A decade later, in a seminal account of the illness, the
French physician Charles Lasegué cautioned, “Woe to the
physician who, misunderstanding the peril, treats as a
fancy without object or duration, an obstinacy which he
hopes to vanquish by medicines” (3). Lasegué further de-
scribed in these patients an unrelenting pursuit of unusu-
ally rigid standards of propriety: “Ever on the watch for
judgements concerning themselves, especially such as are
approved by the family.” These references to a seemingly
incessant demand for the highest possible standards of
behavior and external approval have since found empiri-
cal support in psychometric studies showing significantly
greater inflexibility, restraint, and perfectionism in the
personalities of individuals with anorexia nervosa relative
to healthy comparison subjects (4–7). Of added note, two
other studies (8, 9) found that scores on a measure of per-
fectionism (10) were significantly greater in patients with
anorexia nervosa relative to healthy comparison subjects,
even after long-term weight recovery. In view of evidence
of at least moderate heritability of perfectionism (11) in
studies of human personality, its prominence in anorexia
nervosa, both acutely and postmorbidly, and strong evi-
dence of familial transmission of anorexia nervosa (12), it
has been hypothesized that perfectionism is one of several
related phenotypic temperamental or personality trait
markers expressing a genotypic vulnerability to this illness
(13). However, it remains unknown if perfectionism in an-
orexia nervosa differs by clinical subtype (e.g., subjects
who engage in strict dietary restriction versus purging or
binge eating and purging) or is associated with other core
behavioral features of the illness. Such questions are of
theoretical importance, since personality factors may play
a role in mediating phenotypic aspects of illness behavior
(14) among persons with eating disorders.
The present study examines multidimensional aspects
of perfectionism in a cohort of affected family members
1800 Am J Psychiatry 157:11, November 2000
PERFECTIONISM IN ANOREXIA NERVOSA
selected for the presence of anorexia nervosa. These af-
fected relative pairs were recruited to participate in a mul-
tinational genomic analysis of eating disorders, the goal of
which was to map loci influencing susceptibility to anor-
exia nervosa and bulimia nervosa and to identify behav-
ioral phenotypes associated with genetic heterogeneity in
these syndromes. Data from perfectionism measures,
along with data on obsessional behavior and pathological
eating attitudes and behaviors, were obtained for a total of
322 women with a history of anorexia nervosa. We exam-
ined variation in perfectionism across clinical subtypes of
anorexia nervosa as well as the covariation of perfection-
ism with these behavioral measures.
Method
Subjects
Participants with a history of anorexia nervosa were enrolled in
an international, multicenter study examining the genetic basis
of anorexia nervosa. Specific details of the study background,
methods, proposed genome typing analysis, association analyses,
and candidate gene studies have been previously reported (14).
Relative pairs affected with anorexia nervosa were recruited
through clinic services and advertising at seven sites in North
America and Europe: the University of Pittsburgh, Weill Medical
College of Cornell University, the University of California at Los
Angeles, the University of Toronto, Maudsley Hospital in London,
the University of Munich, and the University of Pennsylvania.
Written informed consent was obtained after the study had been
fully explained.
During the first contact, the initial respondent was questioned
about eating disorders in her first- through fifth-degree relatives.
If it appeared that a relative might be affected, permission to con-
tact said person was obtained. It was necessary that the proband
met criteria for a diagnosis of anorexia nervosa and that the co-af-
fected relative met DSM-IV criteria for anorexia nervosa, bulimia
nervosa, or eating disorder not otherwise specified. Additional
proband-specific requirements were onset of anorexia nervosa
before age 25 and no history of regular binge eating, obesity, seri-
ous medical illnesses, psychotic disorder, bipolar disorder, or
known genetic disorder. The co-affected relative also had to have
no history of obesity, serious medical illnesses, psychotic disor-
der, bipolar disorder, or known genetic disorder. If these criteria
were met, informed consent was obtained and the proband and
relative were enrolled in the study.
All subjects in the current study were female and met modified
DSM-IV criteria for anorexia nervosa disorder (amenorrhea was
not required). The 322 subjects were classified by anorexia nervosa
subtype: restricting (N=146), purging (N=116), or binge eating and
purging (N=60). Seventy-five of the subjects had no relative for the
current analysis. Of the relative pairs, 79 were first-degree rela-
tives, six were second-degree relatives, 11 were third-degree rela-
tives, and seven were greater than third-degree relatives. There
were 11 relative trios among the current data set (i.e., a proband
with two other affected members of the same family). Of the trios,
seven were first-degree relatives (e.g., three sisters), one contained
a proband with a first-degree and a second-degree relative, one
contained a proband with two second-degree relatives, and two
contained a proband with two third-degree relatives. There were
two relative quads—a proband with three other affected members
of the same family. One of the quads was a proband with three
first-degree relatives, and the other quad was a proband with two
first-degree relatives and one second-degree relative. Subjects
were a mean age of 28.2 years (SD=10.4, range=14–65).
The primary goals of this genetic study of anorexia nervosa
were to use family-based association and linkage studies to iden-
tify susceptibility genes for the development of anorexia nervosa.
Thus, the focus of the study was to ascer tain and assess biological
relatives affected with an eating disorder. As a result of this ascer-
tainment strategy, we did not have access to a community com-
parison group of women that could be directly matched to the
women with anorexia recruited for this study. Consequently, for
the current study, data from 44 comparison female subjects who
had served as a comparison group in a family study by Lilenfeld et
al. (15) were used for some of the analyses. These subjects were
recruited by using a commercial mailing list and had no history of
any eating disorder or eating disorder behaviors. They were ex-
cluded if they had weighed less than 90% or more than 125% of
ideal body weight since menarche. The comparison subjects were
a mean of 26.1 years of age (SD=6.2, range=17–41).
Measures
Multidimensional Perfectionism Scale. All subjects com-
pleted the Multidimensional Perfectionism Scale (10), a self-re-
port questionnaire that assesses six aspects of perfectionism
(concern over mistakes, personal standards, parental expecta-
tions, parental criticism, doubts about actions, and organization)
and yields an overall perfectionism score. Eating disorder partici-
pants were instructed to describe their symptoms when they felt
that their eating disorder was most severe. The purpose of this
strategy was to eliminate any ambiguity concerning their symp-
toms. This also allowed us to relate the Multidimensional Perfec-
tionism Scale scores to severity of the eating disorder in the same
time period. Data regarding validity of the Multidimensional Per-
fectionism Scale and its role in psychiatric disorders frequently
comorbid with anorexia nervosa can be found elsewhere (16–19).
Eating Disorder Inventory-2. Two hundred sixty-two anorexia
nervosa subjects (restricting subtype: N=109; purging subtype:
N=105; binge eating and purging subtype: N=48) also completed
the Eating Disorder Inventory-2 (20) (this information was not
collected at the Munich site). Only data from the perfectionism
subscale of the Eating Disorder Inventory-2 will be presented
here. This second measurement of perfectionism was included
because it has been the most frequently used index of perfection-
ism in subjects with eating disorders and thus allows comparison
with other studies. In addition, the relationship between the per-
fectionism subscale of the Eating Disorder Inventory-2 and the
overall measure of perfectionism from the Multidimensional Per-
fectionism Scale has not been assessed in a large cohort of anor-
exia nervosa subjects. By administering both questionnaires, we
attempted a broader, more definitive empirical assessment of
perfectionism in this cohort.
Yale-Brown Obsessive Compulsive Scale. Anorexia nervosa
subjects at each site were also administered the Yale-Brown Ob-
sessive Compulsive Scale, which is a reliable and valid semistruc-
tured interview (21, 22). This instrument first generates a symp-
tom checklist for both current and lifetime symptoms, then
process-oriented questions are asked about the obsessions and
about the compulsions. Both the checklist and the questions were
completed only for the time that obsessions and compulsions
were the most severe.
Yale-Brown-Cornell Eating Disorder Scale. The Yale-Brown-
Cornell Eating Disorder Scale, a reliable and valid semistructured
interview (23, 24) that assesses core preoccupations and rituals
that are related to food, eating, exercise, and the subject’s weight
and body, was administered to each anorexia nervosa subject.
Lifetime and current symptom checklists are generated and pro-
cess-oriented questions are asked about the preoccupations and
about the rituals. For the current analyses, only scores from time
of worst symptoms are used.
Am J Psychiatry 157:11, November 2000 1801
HALMI, SUNDAY, STROBER, ET AL.
Statistical Analyses
For each group of anorexia subjects, Pearson product-moment
correlations were calculated between total score on the Multidi-
mensional Perfectionism Scale and both scores on the perfec-
tionism subscale of the Eating Disorder Inventory-2 and total
score on the Yale-Brown Obsessive Compulsive Scale. Correla-
tions were also computed between total score on the Multidi-
mensional Perfectionism Scale and both lifetime lowest body
mass index and total score on the Yale-Brown-Cornell Eating Dis-
order Scale, as well as with scores on the preoccupation, ritual,
and motivation for change subscales of the Yale-Brown-Cornell
Eating Disorder Scale. Since multiple correlations were con-
ducted, only p values <0.01 were considered as significant. An in-
traclass correlation was computed for the Multidimensional Per-
fectionism Scale total score for sibling pairs by using the SAS
version 7.0 VARCOMP procedure (25).
Analysis of data sets in which some individuals are related is
problematic, since the assumption of independent observations
is violated because paired or clustered data are collected. Thus,
mean differences on dependent measures among women with
anorexia nervosa and comparison subjects were examined by us-
ing generalized estimating equations (26–28). Generalized esti-
mating equations adjust the data to account for a genetic rela-
tionship between some of the subjects. Generalized estimating
equations are a statistical approach based on regression tech-
niques and are used to investigate correlated data, such as panel
studies. It is thus well suited to the data from affected relative
groups used in the current study. In the generalized estimating
equations method, the correlated data are modeled with the
same link function, the same linear predictor setup, and the same
variance function as is used with a generalized linear model in the
independent case. However, in the generalized estimating equa-
tions approach, the covariance structure of the correlated mea-
sures is also modeled. Specifically, by using the generalized esti-
mating equations method, the existence of a relationship
between observations in a particular cluster is assumed, whereas
no relationship is assumed between observations of separate
clusters. The relationships among observations within a cluster
are then estimated by the generalized estimating equations
method and treated as a nuisance variable in analyses. There are
several choices for the form of this working co rrelation matrix , in-
cluding a fixed correlation matrix, the identity matrix, an ex-
changeable correlation matrix, and an unstructured correlation
matrix.
In the current study, biologically related family members con-
stituted each cluster in the generalized estimating equations
analyses. However, because the current study included family
members of varying relatedness (i.e., first-, second-, and third-de-
gree relatives as well as unrelated comparison subjects), the gen-
eralized estimating equations analyses were done in two steps.
First, models were fit to data from the Multidimensional Perfec-
tionism Scale, Eating Disorder Inventory-2, and the Yale-Brown
Obsessive Compulsive Scale by means of the generalized estimat-
ing equations method; an exchangeable working correlation ma-
trix was used for probands and their siblings only to obtain an es-
timate of the familial correlation among these first-degree
relatives. Second, models were re-fit to the entire data set of rela-
tives and unrelated comparison subjects by using familial corre-
lations estimated from the probands and siblings as the user-de-
fined working correlation matrix. The model parameters and
statistics from these models were then used as the final solution.
This approach to the analyses can be considered conservative,
since the proband/sibling correlations used are likely overesti-
mates of the expected correlations among clusters of unrelated
individuals and second- and third-degree relatives. Such overesti-
mation is likely to result in fewer rather than more significant
findings.
In the second model, we examined Multidimensional Perfec-
tionism Scale, Eating Disorder Inventory-2, and Yale-Brown Ob-
sessive Compulsive Scale score differences between the three an-
orexia nervosa subtypes, excluding the comparison subjects, by
using the site at which data were collected (“center”) and the in-
teraction between center and diagnosis as covariates in analyses.
Center was added as an additional clustering variable in the
model, since it was believed that subjects from similar regions of
the world might be more correlated for the scores than those from
different regions. Results from these two models were then com-
pared to determine if the inclusion of additional covariates influ-
enced the results of the contrasts comparing anorexia subtypes. If
they did not, then contrast results from the first model were re-
ported in the tables and text for all groups. If findings did differ,
then contrast results from both models were reported for com-
parison purposes.
An alpha level of p<0.05 was used for analyses of overall effects,
while an alpha level of p<0.01 was used for contrasts between
groups to control for the relatively large number conducted. All
statistical analyses were conducted by using the SAS version 7.0
GENMOD procedure (25).
Results
Table 1 presents the adjusted Multidimensional Perfec-
tionism Scale scores across diagnostic groups. We noted
that the healthy comparison subjects had slightly lower
scores on all subscales of the Multidimensional Perfec-
tionism Scale than previously reported normative data
from a female college population (19). (For reference,
those scores were as follows: total score=67.3, concern
over mistakes=17.7, personal standards=22.5, parental ex-
pectations=13.0, parental criticism=6.4, doubts about ac-
tions=7.7, organization=21.0.) The healthy comparison
subjects in our study had significantly lower scores than
each of the eating disorder groups for all subscales of the
Multidimensional Perfectionism Scale except organiza-
tion, where they differed only from the purging subtype.
The only significant difference between any of the three
anorexia nervosa subgroups was on parental criticism,
where those with the restricting subtype of anorexia ner-
vosa had significantly lower scores than the purging sub-
type. The intraclass correlation (ICC=0.21) for affected sib-
ling pairs was not significant.
There were no significant differences in scores among
the three anorexia nervosa subtypes on the perfectionism
subscale of the Eating Disorder Inventory-2 (restricting:
mean=9.37, SD=0.46; purging: mean=9.12, SD=0.47; binge
eating and purging: mean=9.62, SD=0.62). The scores were
not different from the normative data for anorexia nervosa
subtypes reported by Garner (20). Indeed, the mean per-
fectionism score of the restricting subjects in our study
was in approximately the 50th percentile, and the mean
score of the binge eating and purging subjects was in ap-
proximately the 48th percentile, of the Eating Disorder In-
ventory-2 norms for these subytpes. All three anorexia
nervosa subtypes had mean scores above the nonpatient
college female norms reported for the Eating Disorder In-
ventory-2, with the restricting and purging subtypes in ap-
1802 Am J Psychiatry 157:11, November 2000
PERFECTIONISM IN ANOREXIA NERVOSA
proximately the 82nd percentile and the binge eating and
purging subtype in approximately the 84th percentile.
There were no significant differences between the anor-
exia nervosa subgroups on any of the Yale-Brown Obses-
sive Compulsive Scale scores (Table 2).
There were no significant interactions between site and
diagnosis for any of the scores. When the analyses were re-
run without the interaction, the following scores had sig-
nificant site effects (df=6 and p<0.01 for all analyses): Mul-
tidimensional Perfectionism Scale total score (χ2=23.47),
concern over mistakes (χ2=22.14), personal standards (χ2=
25.08), doubts about actions (χ2=21.03), organization (χ2=
26.25), and obsessions (χ2=16.47) from the Yale-Brown
Obsessive Compulsive Scale. For all Multidimensional
Perfectionism Scale scores that had a significant effect of
site, the Munich site had significantly lower scores than
Los Angeles, Toronto, and London. Munich was also sig-
nificantly below Pittsburgh on four of the Multidimen-
sional Perfectionism Scale scores (total, concern over mis-
takes, personal standards, and organization), and below
New York on personal standards and organization. The ef-
fects of diagnosis between subgroups of anorexia nervosa
with site entered as a covariate were identical to those
without site entered as a covariate. Munich was signifi-
cantly below Los Angeles and Toronto, and London was
significantly lower than Los Angeles, for the Yale-Brown
Obsessive Compulsive Scale obsession score. There were
no site differences for scores on the perfectionism sub-
scale of the Eating Disorder Inventory-2.
The two measures of overall perfectionism (the Multidi-
mensional Perfectionism Scale total and the Eating Disor-
der Inventory-2 perfectionism subscale) were significantly
correlated (p<0.01) for the restricting (r=0.64, df=108),
purging (r=0.71, df=104), and binge eating and purging (r=
0.75, df=47) anorexia nervosa subtypes. The Multidimen-
sional Perfectionism Scale total was also significantly cor-
related with Yale-Brown Obsessive Compulsive Scale total
scores for the restricting (r=0.41, df=145), purging (r=0.28,
df=116), and binge eating and purging (r=0.34, df=58) an-
orexia nervosa subtypes. The Yale-Brown Obsessive Com-
pulsive Scale total score was significantly correlated with
the Eating Disorder Inventory-2 perfectionism subscale
score for the restricting (r=0.41, df=108) and purging (r=
0.22, df=104), but not the binge eating and purging (r=
0.11, df=47), anorexia nervosa subtypes.
Overall perfectionism (total score on the Multidimen-
sional Perfectionism Scale) was also significantly posi-
tively correlated (p<0.01, df=319 for all) with the Yale-
Brown-Cornell Eating Disorder Scale total score (r=0.32)
and its subscales (preoccupations: r=0.28, rituals: r=0.32,
motivation for change: r=0.23) and was negatively corre-
lated with lifetime lowest body mass index (r=–0.20, df=
319, p<0.01). Thus, subjects who were more perfectionistic
when their eating disorder was at its worst generally had
more preoccupations and rituals, were less motivated to
change (higher motivation scores reflect increased pathol-
ogy), and had a lower lifetime lowest weight.
TABLE 1. Multidimensional Perfectionism Scale Scores of Subjects With Anorexia Nervosa, by Subtype, and Healthy Com-
parison Subjectsa
Multidimensional
Perfectionism Scale Item
Anorexia Nervosa Subtype
Comparison
Subjects (N=44) Analysisb
Restricting
(N=145)
Purging
(N=116)
Binge Eating and
Purging (N=59)
Mean SE Mean SE Mean SE Mean SE χ2 (df=3) p
Total score 97.38 1.95 100.99 2.13 102.29 2.53 58.36c1.79 53.58 0.05
Subscale scores
Concern over mistakes 31.81 0.80 32.78 0.83 34.00 1.07 15.05c0.63 55.18 0.05
Personal standards 27.60 0.54 26.77 0.59 27.63 0.59 19.68c0.78 35.86 0.05
Parental expectations 14.31 0.51 15.34 0.49 15.23 0.72 11.09c0.58 23.28 0.05
Parental criticism 10.65d0.40 12.31 0.41 11.81 0.53 5.82c0.39 49.62 0.05
Doubts about actions 12.86 0.33 13.83 0.36 13.57 0.47 6.73c0.32 52.60 0.05
Organization 23.96 0.50 25.50 0.45 23.25 0.77 22.55e0.69 14.42 0.05
aMean scores were adjusted by using generalized estimating equations to account for genetic relationships between some of the subjects.
bEffect of diagnosis on score.
cSignificantly different from scores of each of the anorexia nervosa subtypes (χ2=14.1–66.3, df=1, p<0.01).
dSignificantly different from anorexia nervosa purging subtype (χ2=8.75, df=1, p<0.01).
eSignificantly different from anorexia nervosa purging subtype (χ2=11.1, df=1, p<0.01).
TABLE 2. Yale-Brown Obsessive Compulsive Scale Scores of Subjects With Anorexia Nervosa, by Subtypea
Yale-Brown Obsessive
Compulsive Scale Item
Anorexia Nervosa Subtype
AnalysisRestricting (N=146) Purging (N=117) Binge Eating and Purging (N=59)
Mean SE Mean SE Mean SE χ2 (df=2) p
Total score 14.85 1.03 17.98 1.08 16.62 1.48 4.36 n.s.
Subscale scores
Obsession 7.07 0.52 8.65 0.54 8.22 0.77 4.87 n.s.
Compulsion 7.72 0.55 9.37 0.60 8.37 0.80 3.94 n.s.
aMean scores were adjusted by using generalized estimating equations to account for genetic relationships between some of the subjects.
Am J Psychiatry 157:11, November 2000 1803
HALMI, SUNDAY, STROBER, ET AL.
Discussion
The present study is the largest to date to examine the
role of perfectionism in anorexia nervosa. The findings
from 322 women with anorexia nervosa from seven differ-
ent sites showed that those with anorexia nervosa scored
significantly higher on the Multidimensional Perfection-
ism Scale than healthy comparison subjects. In addition,
they scored higher on the perfectionism subscale of the
Eating Disorder Inventory-2 compared to normative data
for this instrument. These two measures of overall perfec-
tio nism w ere highl y correlated w ithin each o f the t hree an-
orexia nervosa subtypes, which indicates that they were
measuring the same underlying personality construct.
The present results support the notion that perfection-
ism is a prominent feature of the personality background
of individuals affected with anorexia nervosa. The profile
of scores on the Multidimensional Perfectionism Scale in-
dicated that subjects with anorexia nervosa were distin-
guished from healthy comparison subjects by their more
strenuous efforts at, and preoccupations with, avoidance
of mistakes in daily life and of parental criticism, doubts
over the correctness of actions, and more extreme adher-
ence to personal and parental standards of excellence.
Only perfectionistic strivings in organization activities
failed to separate anorexia nervosa subjects from compar-
ison subjects. On balance, our findings concur with evi-
dence of an association between perfectionism and drive
for thinness in nonclinical subjects (29) and elevated per-
fectionism in malnourished (8) and weight-restored pa-
tients with anorexia nervosa (9).
A unique new finding in the present study is the obser-
vation that levels of perfectionism were greater in each of
the three anorexia nervosa subtypes than in the healthy
comparison subjects. Within the clinical sample, anorexia
nervosa subjects who engaged in purging behaviors alone
(i.e., without binge eating) had higher parental criticism
scores than did anorexia nervosa subjects who engaged in
restricting behaviors. Previous studies (30) have shown
that the purging subtype of anorexia nervosa is associated
with more pathology than that found among anorexic pa-
tients who engage in purely restricting behaviors. In a
study with results similar to those of the current study,
Garner and his colleagues (30) found no differences in
scores among these three groups on the perfectionism
subscale of the Eating Disorder Inventory-2. However,
they did report that obsessive-compulsive symptoms (as
measured by the HSCL-58) were more prominent in sub-
jects with the purging subtype of anorexia nervosa than in
those with the restricting subtype. Although in the current
study there were no significant anorexia nervosa subtype
differences on the Yale-Brown Obsessive Compulsive
Scale, the restricting subjects tended to have lower Yale-
Brown Obsessive Compulsive Scale scores than the purg-
ing subjects, which parallels Garner’s findings. From these
patterns, we speculate that increased perfectionism
among purging anorexic patients indicates more desper-
ate efforts at attaining a thin ideal and may be mediated by
greater extremes of perfectionism and related personality
phenotypes.
Differences between anorexia nervosa subtypes were
identical when site was entered as a covariate. Thus, it ap-
pears that the site at which the data were collected did not
significantly influence perfectionism scores in anorexia
nervosa. Site differences for perfectionism were found
only for Munich, whose subjects scored significantly lower
on almost all Multidimensional Perfectionism Scale sub-
scales, except parental criticism and personal standards,
than subjects recruited at the North American and Lon-
don sites. Participants from the Munich site were also
rated significantly lower on obsessive scores from the
Yale-Brown Obsessive Compulsive Scale than subjects
from the North American sites. There are several possibili-
ties that could account for the differential response of Mu-
nich subjects to the perfectionism scales. First, in spite of
careful translation from English to German and back-
translation, there may have been subtleties of perfection-
ism lost in the process of translation. Second, all of the
other sites were in English-speaking countries, or coun-
tries in which English is the major language. It is possible
that there are subtle differences in the German culture
from English-speaking cultures as to how patients re-
spond to questionnaires and express themselves. Third,
the comparison group for the Multidimensional Perfec-
tionism Scale was from the United States; there was no
corresponding German comparison group. The possibility
that perfectionism and obsessionality are less prominent
in German individuals with anorexia nervosa cannot be
discounted.
Hewitt et al. (29) speculated that a strong need for per-
fectionist self-presentation can influence eating behavior
by not allowing the person to display imperfections or ad-
mit to difficulties. Other facets of perfectionism related to
eating disorders are the tendencies of these individuals to
view achievements in black-and-white terms, such that
anything less than perfection is commensurate with fail-
ure. Hewitt et al. (29) suggested that the striving for perfec-
tion is part of a strong drive in anorexia nervosa patients to
gain approval of others by demonstrating conformity to
expectations. In a study that used their own perfectionism
scale, Hewitt et al. (29) found that self-oriented perfec-
tionism was specifically linked to dieting and to concerns
with being thinner. Likewise, Mitzman et al. (31), using a
self-report questionnaire that measured neurotic perfec-
tionism, found that patients with anorexia nervosa had
significantly higher ratings than did healthy comparison
subjects, while Davis et al. (32) found that a high level of
exercise in anorexia nervosa patients was associated with
higher scores on perfectionism.
Anorexia nervosa subjects in the current study were
more perfectionistic than comparison subjects when their
eating disorder was at its worst. Moreover, increasing per-
1804 Am J Psychiatry 157:11, November 2000
PERFECTIONISM IN ANOREXIA NERVOSA
fectionism was associated with lower body weight and
greater prominence of eating preoccupations and rituals,
as well as diminished motivation to change. Thus, greater
severity of eating disorder symptoms was associated with
greater perfectionism.
There are certain limitations in the present study. First,
we used comparison subjects from only a single site. How-
ever, the comparison group had only slightly lower Multi-
dimensional Perfectionism Scale scores than the norma-
tive data reported by Frost and his colleagues (19), and
they were matched closely to our anorexia nervosa groups
with respect to age. Second, familial cases of anorexia ner-
vosa may not be representative of cases of anorexia ner-
vosa selected at random from the general population, spu-
riously inflating the overall prominence of perfectionism
and other personality traits among affected individuals. As
evidence suggests that anorexia nervosa and perfection-
ism may have heritable components (33), and if it is the
case that two traits share genotypic factors in common,
then the perfectionism scores in this group may not gen-
eralize to the larger population of individuals with nonfa-
milial forms of anorexia nervosa. However, as shown by
Strober and colleagues (12), only a small minority of peo-
ple (6.6%) with anorexia nervosa have affected first-degree
relatives. Furthermore, the intraclass correlation of af-
fected sibling pairs was not significant, which indicates
that perfectionism was not more characteristic of sibling
pairs than for nonsiblings. Thus, we believe it is unlikely
that the current findings are seriously confounded by the
use of familial cases.
In sum, this international multisite study provides
strong support for perfectionism as a robust characteristic
of anorexia nervosa. Perfectionism, along with related per-
sonality phenotypes, may constitute quantitative behav-
ioral measures associated with genetic susceptibility for
anorexia nervosa.
Received Dec. 28, 1999; revision received April 28, 2000; accepted
May 24, 2000. From the Eating Disorders Program, New York Presby-
terian Hospital–Westchester Division, Weill Medical College of Cornell
University; the Neuropsychiatric Institute and Hospital, UCLA School
of Medicine, Los Angeles; the Toronto Hospital Department of Psychi-
atry, Toronto; Klinik Roseneck, Hosp ital for Behavio ral Medicine,
Prien Am Chiemsee, Germany; Institute of Psychiatry, Maudsley and
Bethlem Royal Hospital, London; Department of Psychiatry, Univer-
sity of Pennsylvania School of Medicine, Philadelphia; and the Eating
Disorders Module, Western Psychiatric Institute and Clinic, University
of Pittsburgh School of Medicine, Pittsburgh. Address reprint
requests to Dr. Halmi, Eating Disorders Program, New York Pres-
byterian Hospital–Westchester Division, Weill Medical College of
Cornell University, 21 Bloomingdale Rd., White Plains, NY 10605;
kah29@cornell.edu (e-mail).
Supported by a grant from the Price Foundation, Geneva.
The authors thank Kelly Klump, Kathy Plotnikov, and Mayadah Al
Shabbout for their assistance.
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