For the 2016 Annual OCD Conference

1. Perfectionism and Eating Disorders:
Personal and Professional
Perspectives
Steven D. Tsao, Ph.D.
University of Pennsylvania
Jenni Schaefer
Eating Recovery Center

2. Anorexia Nervosa
A. Restriction of energy intake relative to
requirements, leading to a significantly low body
weight in the context of age, sex, developmental
trajectory, and physical health. Significantly low
weight is defined as a weight that is less than
minimally normal or, for children and
adolescents, less than that minimally expected.
– Mild: BMI ≥ 17 kg/m2
– Moderate: BMI 16–16.99 kg/m2
– Severe: BMI 15–15.99 kg/m2
– Extreme: BMI < 15 kg/m2

3. Anorexia Nervosa (con’t)
A. Intense fear of gaining weight or of becoming fat, or
persistent behavior that interferes with weight gain,
even though at a significantly low weight.
B. Disturbance in the way in which one’s body weight or
shape is experienced, undue influence of body weight
or shape on self-evaluation, or persistent lack of
recognition of the seriousness of the current low body
weight.
• Restricting type and binge-eating/purging type
• Lifetime prevalence: 0.9% female, 0.3% males (Hudson
et al., 2007)
• 10:1 female to male ratio

4. Bulimia Nervosa
A. Recurrent episodes of binge eating. An episode of binge eating is
characterized by both of the following:
– Eating, in a discrete period of time (e.g., within any 2-hour period), an
amount of food that is definitely larger than what most individuals would
eat in a similar period of time under similar circumstances.
– A sense of lack of control over eating during the episode (e.g., a feeling
that one cannot stop eating or control what or how much one is eating).
B. Recurrent inappropriate compensatory behaviors in order to
prevent weight gain, such as self-induced vomiting; misuse of
laxatives, diuretics, or other medications; fasting; or excessive
exercise.
C. The binge eating and inappropriate compensatory behaviors both
occur, on average, at least once a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.

5. Bulimia Nervosa (con’t)
• The minimum level of severity is based on the frequency of
inappropriate compensatory behaviors (see below). The level of
severity may be increased to reflect other symptoms and the
degree of functional disability.
– Mild: An average of 1–3 episodes of inappropriate compensatory
behaviors per week.
– Moderate: An average of 4–7 episodes of inappropriate compensatory
behaviors per week.
– Severe: An average of 8–13 episodes of inappropriate compensatory
behaviors per week.
– Extreme: An average of 14 or more episodes of inappropriate
compensatory behaviors per week.
• Lifetime prevalence: 1.5% females, 0.5% males (Hudson et al., 2007)
• 10:1 female to male ratio

6. Binge-Eating Disorder
A. Recurrent episodes of binge eating. An episode of binge eating is
characterized by both of the following:
– Eating, in a discrete period of time (e.g., within any 2-hour period), an amount
of food that is definitely larger than what most people would eat in a similar
period of time under similar circumstances.
– A sense of lack of control over eating during the episode (e.g., a feeling that
one cannot stop eating or control what or how much one is eating).
B. The binge-eating episodes are associated with three (or more) of the
following:
– Eating much more rapidly than normal.
– Eating until feeling uncomfortably full.
– Eating large amounts of food when not feeling physically hungry.
– Eating alone because of feeling embarrassed by how much one is eating.
– Feeling disgusted with oneself, depressed, or very guilty afterward.
C. Marked distress regarding binge eating is present.

7. Binge-Eating Disorder (con’t)
D. The binge eating occurs, on average, at least once a week
for 3 months.
E. The binge eating is not associated with the recurrent use
of inappropriate compensatory behavior as in bulimia
nervosa and does not occur exclusively during the course
of bulimia nervosa or anorexia nervosa.
• Mild: 1–3 binge-eating episodes per week.
• Moderate: 4–7 binge-eating episodes per week.
• Severe: 8–13 binge-eating episodes per week.
• Extreme: 14 or more binge-eating episodes per week.
• Twelve-month prevalence among U.S. adults females and
males is 1.6% and 0.8%, respectively (Hudson et al. 2007)

8. Other Specified Eating or Feeding
Disorder
• Avoidant/Restrictive Food Intake Disorder (ARFID): An eating/feeding
disturbance (e.g., lack of interest in food, avoidance based on sensory
characteristics, concern about aversive consequences of eating) manifested by
persistent failure to meet appropriate nutritional needs associated with:
significant weight loss, significant nutritional deficiency, dependence on
enteral feeding or oral nutritional supplements, or marked interference with
psychosocial functioning.
• Night eating syndrome: Recurrent episodes of night eating, as manifested by
eating after awakening from sleep or by excessive food consumption after the
evening meal. There is awareness and recall of the eating. The night eating is
not better explained by external influences such as changes in the individual’s
sleep-wake cycle or by local social norms. The night eating causes significant
distress and/or impairment in functioning. The disordered pattern of eating is
not better explained by binge-eating disorder or another mental disorder,
including substance use, and is not attributable to another medical disorder or
to an effect of medication.

9. Other Specified Eating or Feeding
Disorder
• Atypical anorexia nervosa: All of the criteria for anorexia nervosa
are met, except that despite significant weight loss, the individual’s
weight is within or above the normal range.
• Bulimia nervosa (of low frequency and/or limited duration): All of
the criteria for bulimia nervosa are met, except that the binge
eating and inappropriate compensatory behaviors occur, on
average, less than once a week and/or for less than 3 months.
• Binge-eating disorder (of low frequency and/or limited duration):
All of the criteria for binge-eating disorder are met, except that the
binge eating occurs, on average, less than once a week and/or for
less than 3 months.
• Purging disorder: Recurrent purging behavior to influence weight or
shape (e.g., self-induced vomiting; misuse of laxatives, diuretics, or
other medications) in the absence of binge eating.

10. The Iceberg metaphor
Eating disorder behavior
Obsessions about food/weight
Body image concerns
Low self esteem/self-worth
Feelings of powerlessness
Family conflict
Interpersonal stressors/issues
Anxiety
Poor emotion regulation skills
Trauma
Perfectionism

11. Perfectionism in our society
• “Gentlemen, we will chase perfection, and we
will chase it relentlessly, knowing all the while
we can never attain it. But along the way, we
shall catch excellence.” - Vince Lombardi
• “The relentless pursuit of perfection” – Lexus
• A perfect game in baseball
• “Picture perfect”

12. Perfectionism
• A multidimensional concept (Franco-Paredes et al., 2005)
– High standards of performance
– Excessively critical evaluations of behavior
– Concern over mistakes
• Szymanski (2011)
– Absence of mistakes or flaws
– Personal standards
– Meeting an expectation
– Order and organization
– “Just right” experiences
– Absolute certainty, knowledge, safety
– The best

13. The role of perfectionism
• Often a part of OCD rituals and sometimes the
primary obsession…
• And…
• A demonstrated risk factor that predates and
exacerbates ED symptoms and remains intact after
weight restoration in anorexia (Fairburn et al., 1999;
Halmi et al., 2000; Kaye et al., 1998)

14. Jenni
My Story

15. Perfectionism in EDs
• Striving for perfect body, shape, or weight
• Exclusively eating “good” foods
• Criticizing “lazy” behaviors
• Striving for perfection in school, work, and
relationships

16. Addressing perfectionism
• Perfectionism can be viewed as a personality trait and not a
disorder
– It‘s both adaptive and maladaptive
– The intentions are good, but behaviors sometimes “pay off” and
sometimes “backfire”

17. Perfectionism payoffs
• Think about a time when your perfectionism
paid off
– What happened?
– How did it feel?
– Did other’s notice? What did they say?
– Did it lead to other rewards?

18. Costs of perfectionism
• Think about that same example, but now focus
on the downsides
– What happened that you didn’t like?
– How much time did you spend on it?
– What other things got neglected or pushed aside
while you were working on this?
– How did it feel?
– How did it impact other people, especially those
closest to you?
– What did it make you think about yourself?

19. Maladaptive perfectionism
• In general, unhealthy perfectionism is operating
when your behavior, choices and strategies are
driven by:
– A fear of failure
– Chronic concerns about making mistakes
– Constant doubting of yourself
– Repeated attempts to live up to others’ expectations
of you
– Always falling short of self-made goals
– Your costs outweigh your payoffs

20. Adaptive Perfectionism
• Pays off more often than it costs you
• Encourages you to achieve high but achievable
standards
• Leads to feelings of satisfaction and increased
self-esteem

21. Addressing perfectionism
• Perfectionism can be viewed as a personality trait and not a
disorder
– It‘s both adaptive and maladaptive
– The intentions are good, but behaviors sometimes “pay off” and
sometimes “backfire”
– [Gray out in end format]
• Goal = Conscientiousness
– Matches perfectionism’s intentions with effective strategies to maximize
adaptive outcomes
• Targeted areas of change
– Increase awareness of pros and cons of current perfectionism
– Analyze cost-benefit ratio of current behaviors
– Explore the impact of perfectionism on goals and standards – consider
client strengths and weaknesses
– Sensitizing people to “mental habits” during evaluations
– Turning failure into learning

22. Cost-Benefit Ratio
• Thinking of the payoffs and the costs, which
one do you experience more often?
• Do the payoffs happen more than the costs?
• Do you spend more time dealing with costs
than basking in the glory of payoffs?
• Regardless of your ratio, ask yourself “How
satisfied am I with this ratio?”
• What area of perfectionism are you most
dissatisfied?

23. Finding lost success
• A story from the pharmaceutical world…
• Striving to achieve a goal through
perfectionism may blind you to valuable
information or perhaps other successes!
• Tunnel vision
• Widening your scope can help you
immediately catch missed opportunities to
feel satisfied, competent, and proud.

24. Perfectionism as habit
• “I don’t know another way”
• Trying to achieve perfection has known
outcome (your payoff-cost ratio)
– What’s the outcome when you try to be “high
average” or “80% perfect”?
• We can only find out by experimenting!
– If it feels “wrong” or “different” it’s working!
– Exposures to feared outcomes of Imperfection

25. Perfectionism as habit
• Procrastination
– Avoid torture of having to do it perfectly
– Preserve illusion of perfection with built in
excused for poor performance
• Try setting a time goal instead
– I’ll work on this for 60 minutes

26. Jenni
My Recovery

27. Thank you!
Steven D. Tsao, Ph.D.
stsao@mail.med.upenn.edu
University of Pennsylvania
Jenni Schaefer
Jenni.schaefer@eatingrecovery.com
National Recovery Advocate,
Eating Recovery Center, Family Institute