Study Confirms Anorexia-Perfectionism Link

N E W   Y O R K, Nov. 17, 2000 -- Nobody’s perfect, but anorexics think they should be, according to a new study that confirms what many eating disorder experts have long suspected.

In the largest study of its kind, an international group of researchers, led by Dr. Katherine Halmi of the Eating Disorders Program of New York Presbyterian Hospital in Manhattan, examined the relationship between anorexia and perfectionism in 322 women from the United States and Europe. She concluded the extent of perfectionism was directly associated with the severity of victims’ anorexia nervosa.

Linking perfectionism and anorexia could help researchers establish if there is a genetic trait that predisposes a person to eating disorders, explains Dr. Suzanne Sunday, an assistant professor of psychiatry at New York Presbyterian and one of the study’s co-authors. “A lot of the evidence [linking perfectionism and anorexia] is anecdotal,” she says. “Now we have hard data in a very large sample.”

In order to find a genetic susceptibility for anorexia, researchers sought patients with relatives who also suffered from eating disorders, and enlisted both in the study. Participants responded to questions on three different standardized tests related to eating disorders, perfectionism and motivation to change.The study was published in the November issue of the American Journal of Psychiatry.

“Perfectionism is present commonly in the backgrounds of persons with anorexia nervosa, suggesting its role as a predisposing personality trait,” study co-author Dr. Michael Strober, director of the Eating Disorders Program at UCLA School of Medicine, said in an e-mail to ABCNEWS.com. “It is suspected that this personality trait may be a marker of genetic risk factors.”

Perfectionism may be a flag for susceptibility to anorexia, but whether anorexia is genetic or environmental, or a mixture of both, remains an open question. In a follow-up study, the scientists will look for possible correlations between the patients’ behavior and their genetics.

Never Skinny Enough

An emotional disorder that manifests itself in the body, anorexia nervosa affects about 8 million Americans, 7 million of whom are women. It is characterized by starvation, compulsive exercising and often by an absence of menstrual cycles. Patients may become preoccupied by food and even engage in food rituals such as cutting up their servings in tiny pieces. Anorexics have a distorted perception of their body and continue to lose weight or obsess over keeping it down long after they have dropped below acceptable levels for their height and age.

Essentially, anorexics can never be skinny enough.

“I see anorexia as one of many manifestations of having a perfectionistic personality,” says Dr. Steven Hendlin, a clinical psychologist in Irvine, Calif., and author of When Good Enough Is Never Enough. Hendlin says a perfectionist is someone who habitually thinks that anything short of perfection in his or her performance is unacceptable. In the case of anorexics, that means living up to unreasonable standards of beauty.

To distinguish between a healthy desire to excel and perfectionism, Hendlin uses the example of a runner who wins a track meet but does not beat his own personal record. The perfectionist, he says, is motivated by fear and focuses on his failure, while the achiever revels in the moment of victory and uses the good feeling to fuel further successes.

Sara Rosin knows about the relationship between perfectionism and weight loss firsthand. The 22-year-old native of Frankemuth, Mich., suffered from anorexia in high school, and then in college developed bulimia — an eating disorder characterized by binge eating, frequently followed by purging through vomiting, abuse of laxatives and/or diuretics, or fasting. “I’ve always been a typical, type-A personality,” Rosin says, meaning she is high-strung.

In an essay Rosin wrote for the National Association of Anorexia Nervosa and Associated Disorders newsletter, she describes the struggle overachieving anorexics experience. “Somehow when females heard the message ‘You can be anything you want to be,’ they inferred that to mean ‘You should be everything you possibly can be! Oh — and don’t forget to be the best at it all!’”

A cross-country runner in school, Rosin says her perfectionism drove her to always push herself harder. “I felt like if I could do three miles, good. If I could do five miles, better.” Conversely, when it came to food, the less she consumed, the better. When her weight fell to 76 pounds, Rosin finally realized her all-consuming drive could kill her.

Untreated, anorexia can be fatal. The most common cause of death in a longtime anorexic is low serum potassium, which can cause an irregular heartbeat and eventual heart failure.

Nature vs. Nurture

Hendlin says anorexics learn as children that they will not be loved unless they are perfect. He is convinced perfectionism is due to nurture, not nature. “[Perfectionism] is not a trait,” he says. “It’s learned by what you do as a kid and it always has to do with authority figures.”

But many experts believe life experience is only one of the factors that influence whether a person will have an eating disorder. Dr. Walter Kaye, a professor of psychology at the University of Pittsburgh Medical Center and another of the study’s co-authors, says, “A lot of people diet in this society, but not everyone ends up with an eating disorder.”

Kaye and his fellow researchers now suspect anorexia may be linked to the family of genes associated with serotonin, a neurotransmitter connected to mood. By analyzing study participants’ DNA, they hope to find patterns that are similar in anorexic family members but different from those of people without eating disorders.

Finding a genetic marker for anorexia could help to better target treatment for the disorder — possibly with drugs. Treatment for anorexia currently consists of hospitalizing patients to get their weight back up, followed by therapy, which can continue for years.

Today, after extensive therapy, Rosin says she still has to check herself for negative thought patterns and unrealistic expectations. She is wary of the messages she hears from herself and others about women, weight and perfection.

“I basically realized I am not perfect,” Rosin says. “Life’s not perfect. I don’t want to be perfect. I realized I am happy with what I have.”