Perfectionism and Eating Disorders: Symptoms and Treatment Options

Many individuals with eating disorders also struggle with perfectionism. This can show up as having high standards, struggling with even small mistakes, and feeling chronically dissatisfied. Along with perfectionism, people with eating disorders are also more likely to be diagnosed with obsessive-compulsive disorder, obsessive-compulsive personality disorder, anxiety and depression. Evidence-based therapies like cognitive behavioral therapy and acceptance and commitment therapy can be life-changing as individuals learn how to let go of their rigid standards and high levels of self-criticism as they start to heal.

Perfectionism and eating disorders

Perfectionism is a personality trait characterized by an intense drive to achieve perfection or appear flawless, often resulting in negative emotional consequences. Patients with eating disorders, including anorexia nervosa and bulimia nervosa, exhibit elevated levels of perfectionism.¹ Perfectionism, along with other personality traits, often influences how eating disorders develop and progress, offering valuable insights for treatment strategies.

Traits of perfectionism

Perfectionism is a complex concept and is often described in two domains, perfectionist strivings and perfectionist concerns^2,3 :

• Perfectionist strivings
  • High standards
  • Satisfaction
• Perfectionist concerns
  • Concern over mistakes
  • Dissatisfaction
  • Details and checking
  • All-or-nothing thinking

H3: Perfectionist strivings

Perfectionistic strivings involve setting and pursuing extremely high personal standards, focusing on flawlessness and a strong desire for excellence. Sometimes this is referred to as adaptive perfectionism – a healthy form of striving characterized by setting high personal standards while remaining flexible, motivated and capable of adapting to setbacks.

Perfectionist strivings by themselves are not always harmful and alone are less strongly associated with disordered eating behavior.⁴ For some, high personal standards and a strong motivation to succeed are also associated with greater well-being.⁵

However, perfectionist tendencies can become problematic when combined with excessive self-criticism, worry over mistakes and ongoing dissatisfaction despite achievements, collectively known as perfectionist concerns.

High standards

High standards, also called personal standards or self-oriented perfectionism, are characterized by setting excessively high performance goals and placing great importance on them for self-evaluation.

Personal standards have been found to be higher in those with anorexia nervosa and atypical anorexia nervosa (A-AN) compared to those with bulimia nervosa.⁶ Additionally, those who engage in restrictive disordered eating behaviors, such as those with the restricting subtype of anorexia nervosa (AN-R), show higher personal standards than those who engage in binge eating and purging.⁷

 It’s important to note that there were few differences between personal standards of those with anorexia nervosa and A-AN, which indicates that low weight itself is not a sign of perfectionist striving.⁷

A couple of examples of high standards in eating disorders include:

• Setting a firm limit of 1,000 calories a day
• Pushing through illness or injury to keep up with an exercise regimen

Satisfaction

Satisfaction is the ability to feel positive and accomplished after completing a goal or task. Although there is limited research specifically examining satisfaction in eating disorder populations, feeling satisfied – rather than chronically dissatisfied – after reaching a goal is generally considered a sign that perfectionism functions in an adaptive, healthy way.

Perfectionist concerns

Perfectionist concerns refers to the tendency to worry excessively about making mistakes, fear negative evaluation and experience persistent self-criticism when personal standards are not perfectly met.

The presence of perfectionist concerns can turn perfectionism maladaptive as individuals struggle under the weight of their own expectations.

Concern over mistakes

Reactivity to mistakes, also called concern over mistakes, is the tendency to respond disproportionally and negatively to errors, see mistakes as failure and believe that one will lose the respect of others following failure.

Concern over mistakes has been found to be elevated in both patients with anorexia nervosa and bulimia nervosa.⁷ It is also associated with eating disorder symptoms, including⁷:

• Eating concerns
• Behavioral restraint
• Body checking

Some common examples of reactivity to mistakes are:

• Feeling extreme guilt after eating more than planned at a meal, even a small portion
• Panicking after missing a scheduled workout, fearing it will undo all previous “progress”

Dissatisfaction

Dissatisfaction is the tendency to feel as though one is not meeting their standards, that something isn’t good enough or that something is always wrong.

Dissatisfaction is rarely examined on its own, but it's common for those with eating disorders to experience ongoing dissatisfaction. Even when goals like size or weight are achieved, new standards are often set. This can help sustain behaviors like:

• Food restriction
• Rigid food rules
• Compulsive exercise

This can appear as persistent negative thoughts, like:

• “I stuck to my meal plan all week, but it still wasn’t enough. I need to do more.”
• “I ran for 30 minutes, but I didn’t push myself hard enough.”

Doubts about actions

Doubts about actions refers to the tendency to be thorough, to obsess about details and to recheck one’s work. This might present as:

• Body checking or frequent weighing
• Questioning whether caloric intake was calculated correctly
• Concern over whether step counts are accurate
• Reweighing food or checking nutrition labels multiple times

All-or-nothing thinking

All-or-nothing thinking related to perfectionism is the cognitive distortion that if something isn't perfect, it must be a failure, or that if one can't do something perfectly, it shouldn't be done at all.

All-or-nothing thinking is a common cognitive distortion that often occurs in those with eating disorders, popping up in thoughts like:

• “I had a slice of bread, so my whole diet is ruined. I should just skip dinner.”
• “I missed yesterday’s run, so today doesn’t matter either; I might as well do nothing.”

Perceived pressure from others

Perceived pressure from others, known as socially prescribed perfectionism, is the tendency of perfectionists to feel that others have high expectations, expect them to be perfect or are critical of their performance.

For patients with bulimia nervosa, perceived pressure from others was linked to more severe eating disorder symptoms.⁸

Social expectations can pop up a lot in eating disorder thoughts. Examples include:

• “My parents will think less of me if I gain weight my freshman year.”
• “What will the team think if I gain weight?”

Perfectionism and dual diagnosis

Not all perfectionists will be diagnosed with two or more mental health conditions. But individuals with eating disorders commonly have multiple diagnoses.

Obsessive-compulsive personality disorder

Obsessive-compulsive personality disorder (OCPD) is present in 22% of individuals with anorexia nervosa restricting subtype (AN-R), compared to 8% in the general population.⁹

Perfectionism is a prominent trait in both anorexia nervosa and OCPD, often expressed as rigid standards for body weight, shape or dietary control. For example, individuals may focus obsessively on "ideal" body image and follow rigid routines, similar to the inflexible standards and orderliness seen in OCPD.

Obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is common in patients with eating disorders, with a lifetime prevalence of around 14%.⁶

Perfectionism in eating disorders and OCD often appear as anxiety-driven behaviors aimed at avoiding perceived failure or mistakes. Doubt about actions is connected to both OCD and eating disorders.¹⁰ This doubt can lead to anxiety and the use of compulsive behaviors to try to reduce that anxiety, such as:

• Compulsive dieting
• Frequent weighing
• Rigid food rituals

Depression and anxiety

Depression and anxiety are common co-occurring conditions in those with eating disorders, affecting up to 75% and 62%, respectively.^11,12 Perfectionism is also associated with higher anxiety and depression and worse outcomes in adults with anorexia nervosa.¹⁰

Depression and anxiety are linked with eating disorders through concern over mistakes.¹⁰ When mistakes are interpreted as unacceptable or as evidence of personal failure, even small errors might trigger intense anxiety and self-criticism. Over time, this pattern can increase both anxious distress and depressive thinking, which can reinforce disordered eating behaviors that are used to prevent, correct or cope with perceived mistakes.

Psychotherapy for perfectionism

Perfectionism is common in people with eating disorders. The personality traits listed below are also common in people with eating disorders:

• Impulsivity
• Negative affect
• Harm avoidance
• Obsessive-compulsivity
• Detachment

Therapy can help these individuals find new coping skills to reduce the continuous loop of negativity and criticism that often seems ever-present. Take a look at some of the most effective therapies for helping people overcome perfectionism and related traits.

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is a structured, evidence-based treatment that helps reduce perfectionism by targeting the thoughts and behaviors that maintain rigid, self-critical standards.

Treatment focuses on identifying perfectionistic beliefs, developing more flexible standards, and reducing behaviors like excessive checking or avoidance. Research shows that CBT can significantly reduce perfectionism and is also associated with improvements in eating disorder symptoms.¹³

Temperament-based therapy with supports

Temperament-based therapy with supports (TBT-S) is a neurobiologically informed intervention that can be used in conjunction with psychotherapy that targets the fundamental factors contributing to eating disorder development, including biological processes, brain function, genetics and personality traits.

 A key part of TBT-S is helping individuals adapt entrenched personality traits so they support recovery rather than uphold the eating disorder. Research shows that people with anorexia nervosa and bulimia nervosa experience significant reductions in eating disorder symptoms through TBT-S.¹⁴

Acceptance and commitment therapy

Acceptance and commitment therapy (ACT) focuses on developing psychological flexibility instead of avoiding, eliminating or suppressing uncomfortable feelings like failure or fear of mistakes.

Emerging research indicates that ACT is an effective treatment for clinical perfectionism that can help reduce it by reducing avoidance and rigid adherence to unrealistic standards.¹⁵

Compassion-focused therapy

Standard compassion-focused therapy (CFT) emphasizes developing compassion and addressing emotional challenges more broadly.

Compassion-focused therapy for eating disorders (CFT-E) adapts these principles to target the complex factors underlying eating disorders, including perfectionism, rigid standards and self-criticism. CFT-E incorporates interventions to reduce harsh self-evaluation and increase tolerance for mistakes while also addressing distorted body image, unhealthy eating behaviors and perfectionistic concerns.

Find help for perfectionism and eating disorders

Perfectionism is a common challenge for people living with an eating disorder and for those with dual diagnosis, often making everyday decisions feel more difficult. While it can be frustrating, support is available to help manage these behaviors.

References

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