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Perfectionism Among Women Seeking Help for Deliberate
Self-Harm and/or Eating Disorders: A Comparative Study

presented by

Anne Elisabeth Kubal

has been accepted towards fulfillment
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PERFECTIONISM AMONG WOMEN SEEKING HELP FOR DELIBERATE SELF-
HARM AND/OR EATING DISORDERS: A COMPARATIVE STUDY

By

Anne Elisabeth Kubal

A DISSERTATION

Submitted to
Michigan State University
in partial fulﬁllment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY
Department of Counseling, Educational Psychology, and Special Education

2005

ABSTRACT

PERFECTIONISM AMONG WOMEN SEEKING HELP FOR DELIBERATE SELF -
HARM AND/OR EATING DISORDERS: A COMPARATIVE STUDY

By

Anne Elisabeth Kubal

Deliberate self-harm (DSH) or self-injury is deﬁned as the deliberate destruction
or alteration of one’s own body, performed without suicidal intent. Anecdotal reports
have suggested that perfectionism is a common characterological trait among individuals
who engage in DSH, but the relationship between DSH and perfectionism has not been
studied empirically. As a preliminary means of exploring the contribution of
perfectionism in the development and maintenance of DSH, the primary goal of the
present study was to explore the prevalence and nature of perfectionism within a DSH
population compared to an eating disorder population and a comorbid eating
disorder/DSH population. Both theoretical and empirical links have been established
between DSH and eating disorders, and between eating disorders and perfectionism. A
secondary goal of this study was to explore the possibility that within DSH, eating
disorder, and comorbid eating disorder/DSH populations, individuals who self-identify as
survivors of childhood abuse or neglect exhibit differential rates of interpersonal,
intrapersonal, and self-presentational dimensions of perfectionism as compared to
individuals who do not self-identify as survivors of childhood abuse or neglect. Due to
the controversies surrounding a single deﬁnition of perfectionism and the unique aspects

of this construct assessed by various perfectionism measures, multiple measures of

45
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perfectionism were utilized in an attempt to more fully understand the relationships
between perfectionism, DSH, and eating disorders.

Multivariate analyses of variance were conducted to examine commonalities and
differences between groups. The results support the importance of examining trait
perfectionism from a multidimensional perspective and support the importance of
examining self-presentational styles of perfectionism as an important component of
perfectionistic behavior. Commonalities and differences in trait and self-presentational
perfectionism are discussed in terms of implications for clinical practice. Based on the

results of this study, directions for future research are suggested.

This dissertation is dedicated to Dr. Joan Pfaller (1953-2003). With wisdom, guidance,
and generosity of spirit, she modeled the type of psychologist I strive to be.
She is missed.

iv

ACKNOWLEDGMENTS

There are numerous individuals I would like to acknowledge. First and foremost,
I want to express deep gratitude to the women who participated in this research and
openly shared their struggles and experiences. This study would have been impossible
without their generosity. I also want to express gratitude to the therapists who assisted
with data collection and trusted me to protect the welfare of their clients.

I wish to thank all of the individuals who provided me with guidance throughout
the development and completion of this project. Without the encouragement of Karen
Conterio and Dr. Wendy Lader, this project may have never come to fruition. I am
deeply indebted to them for their encouragement and support. I wish to thank Dr. Ken
Rice, who fostered my interest in research in general and my interest in the study of
perfectionism in particular. Dr. Nancy Crewe, my advisor and dissertation committee
chair, deserves special thanks for her mentorship, advice, and encouragement. I would
also like to thank Dr. John Carlson, Dr. John Kosciulek, and Dr. Tom Novak, my
remaining committee members, for their support and guidance. Finally, I am deeply
indebted to my family and cohort members for their unending support and

encouragement; without them, I would not have succeeded.

TABLE OF CONTENTS

LIST OF TABLES ................................................................................. viii
CHAPTER 1
Introduction ............................................................................................ l
Deliberate Self-Harm and Eating Disorders .............................................. 4
Perfectionism ................................................................................. 6
Perfectionism and Eating Disorders ........................................................ 7
Problem Statement ........................................................................... 9
Research Questions ........................................................................ 10
Hypotheses .................................................................................. 11
CHAPTER 2
Literature Review ..................................................................................... 12
Deliberate Self-Harm ....................................................................... l3
Conceptual Shifts in the Understanding of DSH ............................. 13
DSH as suicidal behavior ................................................ 13
DSH as a distinct syndrome ............................................. 14
DSH as a subtype of pathological mutilation ......................... 16
Diagnostic Dilemmas Associated with DSH ................................... l9
Differences between DSH and suicidal behavior. . . . . . . . . . . .19
DSH and personality disorders ......................................... 21
Characteristics of the DSH Population .......................................... 22
Risk Factors in the Development of DSH ..................................... 24
Child abuse and trauma ................................................... 25
Dissociation ................................................................ 28
Childhood illness and surgeries ......................................... 28
Body alienation ............................................................ 29
Disruptions in parent-child attachment ................................ 3O
Perfectionism ............................................................................... 32
Deﬁning Perfectionism ........................................................... 33
Multidimensional Conceptualizations of Perfectionism ...................... 34
Perfectionism and Eating Disorders ...................................................... 37
Limitations of Early Research Examining Perfectionism and Eating
Disorders ........................................................................... 38
Adaptive and Maladaptive Perfectionism within Eating Disorder
Populations ......................................................................... 41
Intrapersonal and Interpersonal Dimensions of Perfectionism within
Eating Disorder Populations ..................................................... 44
Perfectionistic Self-Presentation within Eating Disorder Populations. . ...48
Eating Disorders and DSH ................................................................ 51
Eating Disorder and DSH Comorbidity Estimates ........................... 52

Theoretical Explanations for Eating Disorder and DSH Comorbidity. . ...53

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Diagnostic Explanations for Eating Disorder and DSH Comorbidity.. . ...55

Repetitive self-harm syndrome ......................................... 55

Multi-impulsive personality disorder .................................. 56

Multi-impulsive bulimia ................................................ 57

Borderline personality disorder ......................................... 58

Perfectionism and DSH .................................................................... 60
CHAPTER 3

Methodology .......................................................................................... 66

Participants .................................................................................. 66

Instruments .................................................................................. 67

Demographic questionnaire ...................................................... 67

Help-Seeking and Treatment History Questionnaire ......................... 67

Frost Multidimensional Perfectionism Scale (MPS; Frost et al., 1990). . .68
Multidimensional Perfectionism Scale (MPS; Hewitt & F lett, 1991). . ....74

Perfectionistic Self-Presentation Scale (PSPS; Hewitt et al., 2003) ........ 75
Procedure ..................................................................................... 71
Data Analyses .............................................................................. 75
CHAPTER 4
Results ............................................................................................... 77
Research Question 1 ...................................................................... 76
Eating disorder group ............................................................ 78
DSH group ........................................................................ 79
Comorbid eating disorder/DSH group .......................................... 80
Perfectionism analyses by group ................................................ 81
Research Question 2 ....................................................................... 84
Childhood neglect ................................................................. 85
Childhood sexual abuse .......................................................... 87
Childhood physical abuse ........................................................ 88
CHAPTER 5
Discussion ............................................................................................ 9O
Differences in Dimensions of Perfectionism ........................................... 90
Implication of Findings ..................................................................... 96
Limitations .................................................................................. 99
Directions for Future Research .......................................................... 101
APPENDIX A: Request for Therapist Assistance ............................................ 103
APPENDIX B: Participant Recruitment Form ................................................ 104
APPENDIX C: Informed Consent .............................................................. 107
APPENDIX D: Consent Form for use at Linden Oaks at Edward Hospital .............. 109
APPENDIX E: Demographic Questionnaire .................................................. 114
APPENDIX F: Help-Seeking and Treatment History Questionnaire ...................... 116
REFERENCES ..................................................................................... 122

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LIST OF TABLES

Conceptualizations of Perfectionism ............................................................. 36
Means and Standard Deviations by Diagnostic Group ........................................ 82
Means and Standard Deviations by Childhood Neglect History .............................. 86
Means and Standard Deviations by Childhood Sexual Abuse History ...................... 87
Means and Standard Deviations by Childhood Physical Abuse History .................... 89

viii

 

 

 

 

CHAPTER 1

Introduction

Deliberate self-harm (DSH) constitutes a poorly understood and understudied
psychological phenomenon. Although DSH has been documented as early as Biblical
times, the psychological community has only recently begun to recognize it as a serious
problem that affects many people throughout their lifetimes (Smith, Cox, & Saradjian,
1999). Scant attention has been given to deliberate self-harm within the empirical
literature.

Deliberate self-harm can be deﬁned as purposeful injury to the body without the
intent to commit suicide. The term excludes individuals who self—injure due to psychotic
disorders or organic disorders, such as developmental disabilities. The most common
forms of DSH include skin cutting and skin burning (Conterio & Lader, 1998). However,
DSH methods can range from scratching until one bleeds to breaking bones.
Approximately 75% of individuals who self-harm engage in more than one method
(Conterio & Lader, 1998).

There is a paucity of empirical literature speciﬁcally examining DSH. The
majority of existing research focuses on one of three populations: suicidal patients in
psychiatric treatment, individuals seen in emergency wards for medical care, and
epidemiological studies. Minimal attention has been directed to the study of DSH among
individuals speciﬁcally seeking non-crisis psychological treatment. Furthermore, the
majority of studies provide no theoretical framework from which to understand DSH

behaviors and do not differentiate between DSH and suicide attempts. Conceptually,

DSH and suicidality must be distinguished: Deliberate self-harm does not involve an
expressed wish to die. According to van der Kolk, Perry, and Herman (1991), “The
literature has suggested that self-injurious behavior is quite distinct from suicide attempts
in intent, lethality, age at onset, sex ratio, and interpersonal meaning” (p. 1665). DSH is
best understood as a maladaptive coping strategy employed to manage psychological
tension (Conterio & Lader, 1998; Himber, 1994; Shearer, 1994; Strong, 1998). It is
viewed as a maladaptive method of regulating mood and emotion.

In the United States, DSH rates are increasing, but actual prevalence is difﬁcult to
determine due to underreporting and misdiagnosis (Conterio & Lader, 1998). Current
estimates are that 1,400 out of 100,000 people in the general population engage in some
form of self-injury (Conterio & Lader, 1998). Within a psychiatric population, between
4% and 10% of patients are estimated to injure themselves intentionally (Paul, Schroeter,
Dahme, & Nutzinger, 2002). The majority of self-harm behaviors begin during
adolescence, and clinical data indicate that approximately two-thirds of those who seek
treatment for self-harm are female (Favazza & Conterio, 1989; Simeon & Hollander,
2001).

Despite the growing awareness of DSH within the psychological literature, there
is no generally accepted treatment paradigm and signiﬁcant gaps still exist in the
empirical research. Recent research has identiﬁed both interpersonal and intrapersonal
psychological factors associated with DSH, including poor self-esteem, depression,
hopelessness, substance abuse, poor problem-solving skills, insecure attachment, poor

body image, eating disorders, and a history of childhood trauma, including physical

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abuse, sexual abuse, and emotional abuse or neglect (Alderman, 1997). Yet, it remains
unclear how these factors interact and increase the risk for DSH behaviors.

The empirical evidence suggests that DSH is of heterogeneous etiology,
overwhelmingly linked to interpersonal stress (Dallam, 1997), and a unitary etiological
formation is unlikely (Favazza, 1996). Among the general population, adolescent
females with a history of child abuse, childhood trauma, and/or eating disorders represent
speciﬁc at-risk groups. Research has consistently found links between DSH and
childhood abuse, DSH and other forms of childhood trauma, and between DSH and
eating disorders. For example, in one study of 240 repetitive, female self-harmers, 54%
of the sample described their childhood as “miserable” when given a choice of adjectives
(Favazza & Conterio, 1989). In the same study, approximately two-thirds of the
participants reported histories of childhood abuse: 29% of participants reported both
sexual and physical abuse, 17% reported only sexual abuse, and 16% reported only
physical abuse (F avazza & Conterio, 1989).

Physical and sexual abuse during childhood and adolescence have also been
found to be reliable predictors of the frequency and severity of self-cutting, one of the
most common methods of DSH (van der Kolk et al., 1991). Furthermore, van der Kolk et
a1. (1991) found that childhood sexual abuse survivors were more likely than physical
abuse survivors to engage in DSH. Despite these strong correlations, many individuals
who engage in DSH behaviors do not have abuse histories (Alderman, 1997). However,
because the empirical literature base has focused so heavily on experiences of early
deprivation and abuse as etiological factors precipitating DSH, therapists often make the

erroneous assumption that there must be a history of physical abuse, sexual abuse, or

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other childhood trauma in the background of all clients who engage in DSH (Selekman,
2002). To the contrary, several researchers have found no evidence of childhood sexual
or physical abuse among individuals engaging in DSH (Brodsky, Cliotre, & Dulit, 1995;
Zweig-Frank, Paris, & Guzder, 1994). Childhood abuse and trauma is neither a
necessary nor sufﬁcient condition in the development of DSH. Thus, it appears that
characterological variables may inﬂuence the impact of childhood abuse in the
development of DSH behaviors.
Deliberate Self-Harm and Eating Disorders

The link between DSH and eating disorders has been highlighted in historical
cases, anecdotal reports, and is beginning to receive increased attention in the empirical
literature. Although strong correlations between DSH and eating disorders have been
found in the limited existing literature, the level of comorbidity varies greatly by study.
For example, Sansone, Levitt, and Sansone (2003) estimated the prevalence of DSH
within an eating disorder population at 25%, regardless of the speciﬁc eating disorder
diagnosis or treatment setting. Farber (2000) estimated the prevalence of DSH among
individuals with bulimic behavior to be between 8.9% and 26.6%, but reported between
57% and 93.3% of the DSH population to have associated eating disordered behavior. In
contrast, based on an examination of several studies, Favazza (as cited in Conterio &
Lader, 1998) estimated that 40.5% of bulimics and 35% of anorexics engage in DSH.
Other studies have found that up to 61% of those who engage in DSH suffer from a
comorbid eating disorder (Paul etal., 2002).

Both DSH and eating disorders are remarkably similar in terms of sex ratio, age

of onset, and psychological correlates (Farber, 2000). Common psychopathological

factors underlying both DSH and eating disorders include poor body image, low self-
esteem, high levels of impulsivity and obsessive compulsive behavior, and greater
dissociation. Comorbid DSH and eating disorders have also been found to be sequelae of
childhood trauma and abuse (Cross, 1993, Farber, 1997, Miller, 1994). Because of these
similarities, several researchers have considered DSH and eating disorders to be different
manifestations of the same underlying deﬁcits in self-care capacities and emotional
regulation (Conterio & Lader, 1998; Favazza, 1996; Miller, 1994).

The high comorbid rates of DSH and eating disorders may also be explained as a
function of borderline personality disorder. Self-injurious behavior is one of the nine
diagnostic criterion of borderline personality disorder, and binge eating is listed as an
area of impulsivity included under another diagnostic criterion of borderline personality
disorder. However, using borderline personality disorder as an exclusion criteria, Paul et
a1. (2002) still found more than a 30% lifetime occurrence rate of DSH among an eating
disorder population. Comorbid DSH and eating disorders are also common among those
diagnosed with posttraumatic stress disorder (Herman, 1992; Shapiro & Dominiak, 1992;
van der Kolk et al., 1991; Vanderlinden & Vandereycken, 1997) and dissociative
disorders (Bliss, 1980; Herman, 1992; Shapiro, 1987; van der Kolk et al., 1991;
Vanderlinden & Vandereycken, 1997). As suggested by Farber (2000), “There is a
remarkably strong empirical association between eating-disordered behavior and self-
mutilation that has major implications for understanding self-harm processes (p. 35).

Further research is needed to explore the association between DSH and eating
disorders, and to understand the variables which uniquely and interactively contribute to

the comorbidity of these two forms of self-abuse. The differential rates of DSH among

childhood abuse and trauma survivors suggest the presence of mediating and moderating
variables in the etiology of DSH, and the similar psychopathological correlates between
DSH and eating disorders suggest that characterological variables inﬂuencing the
development of eating disorders may serve similar functions in the adoption of DSH as a
coping strategy. Perfectionism constitutes such a variable.
Perfectionism

A recent proliferation of empirical studies have identiﬁed perfectionism as a
multidimensional construct with positive and negative aspects on both a personal and
interpersonal level. Increasingly recognized as a signiﬁcant predictor of psychological
adjustment, theorists have yet to agree on a single deﬁnition of perfectionism, but instead
have focused on delineating different subtypes and dimensions of perfectionism in
relation to psychological adjustment. For example, Hamachek (1978) originally
distinguished between normal perfectionism and neurotic perfectionism, whereas Terry-
Short, Owens, Slade, and Dewey (1995) distinguished between positive and negative
perfectionism. Both normal and positive subtypes of perfectionism involve the setting of
high personal standards and appear to be driven by achievement strivings. In contrast,
neurotic and negative perfectionism subtypes appear to be driven by a fear of failure.

Hewitt and Flett (1991), recognizing the limitations of conceptualizations of
perfectionism which focus solely on intrapsychic qualities and self-directed
perfectionistic cognitions, outlined three dimensions of perfectionism based on the source
and target of perfectionistic expectations: self-oriented perfectionism, other-oriented
perfectionism, and socially prescribed perfectionism. Self-oriented perfectionism

involves excessively high self-standards; other-oriented perfectionism involves holding

others to unrealistically high standards; and socially prescribed perfectionism involves
the perception that others hold unrealistically high standards for oneself. Self-oriented
perfectionism, an intrapersonal dimension, is generally described as adaptive in nature.
Other-oriented and socially prescribed perfectionism, both interpersonal dimensions, are
typically described as maladaptive in nature.

The recognition of the complex nature of perfectionism has led to the
development of several multidimensional perfectionism scales and increased use of
multivariate cluster analyses to empirically distinguish between “adaptive” and
“maladaptive” perfectionism. Adaptive perfectionism, characterized by high personal
standards and a preference for order and organization, has been linked to achievement
orientation, conscientiousness, academic adjustment, self-efﬁcacy, positive affect, high
self-esteem, and social ease. In contrast, maladaptive perfectionism, characterized by
concerns about making errors, self-doubt concerning one’s own behavior, and an overly
critical relationship with one’s parents, has been linked to depression, anxiety and worry,
suicide risk, low self-esteem, hopelessness, and eating disorders.

Perfectionism and Eating Disorders
An increasing amount of literature has focused on the role of perfectionism in the
development and maintenance of eating disorder symptomatology. In fact, the quest for
body perfection is considered a core feature of anorexia nervosa, bulimia nervosa, and
other eating-disordered behavior. Initial research in this area, based on a unidimensional
conceptualization of perfectionism, supported the proposition that perfectionism is a
common premorbid personality characteristic within an anorexic population (Dally, 1969;

Hamli, Goldberg, Eckert, Casper, & Davis, 1979). Research also supported a relationship

between perfectionism and bulimia nervosa. The early research linking perfectionism to
eating disorders was strengthened by later studies which found higher incidences of
perfectionism within eating disorder populations when compared to control groups
(Goldner, Cockell, & Srikameswaren, 2002). Yet, the empirical ﬁndings have not been
unequivocal.

Several researchers have found no signiﬁcant differences in the levels of
perfectionism within an eating disorders population when compared to a general
psychiatric population (Hurley, Palmer, & Stretch, 1990) or a weight-preoccupied control
group (Garner, Olmstead, Polivy, & Garﬁnkel, 1984), and Blouin, Bushnik, Braaten, &
Blouin (1989) found comparable levels of perfectionism in an eating disorder group and a
diabetic group. One explanation for these ﬁndings may be related to differences in levels
of perfectionism related to speciﬁc diagnostic subtypes of eating disorders. However,
while some authors have advocated the position that anorexics and bulimics can be
distinguished on the basis of characterological variables (Casper, 1983), others have
posited that perfectionism is a key characteristic of both disorders (Beebe, 1994;
Heatherton & Baumeister, 1991; Slade, 1982).

The differential ﬁndings may be best understood in relation to the manner in
which perfectionism was measured in each study. Given the complex etiology of eating
disorders, unidimensional models of perfectionism may not be sophisticated enough to
capture the true relationship between perfectionism and eating disordered behavior. For
example, using a multidimensional measure of perfectionism, Hewitt, Flett, and Ediger
(1995) found a signiﬁcant relationship between self-oriented perfectionism and eating

disorder symptoms, whereas socially prescribed perfectionism was signiﬁcantly related to

issues of low self-esteem and appearance concerns, issues which are prevalent in an
eating disorders population. Although continued research is needed to further clarify the
relationship between different dimensions of perfectionism and eating disorder
symptomatology, this line of research may help delineate the relationship between eating
disorders and DSH.

Problem Statement

Anecdotal reports suggest perfectionism is a common characterological trait
among individuals who engage in DSH, but the relationship between DSH and
perfectionism has yet to be studied empirically. However, both theoretical and empirical
links have been established between DSH and eating disorders, and between eating
disorders and perfectionism. Therefore, it is reasonable to assume that perfectionism may
constitute a yet unstudied vulnerability factor in the development and maintenance of
DSH.

An examination of perfectionism within a DSH population may help explain the
differential rates of DSH among survivors of childhood abuse and trauma, help explain
the high comorbidity between DSH and eating disorders, and lead to advances in the
treatment of DSH. A clinically relevant aspect of perfectionistic behavior involves
perfectionistic self-presentation, or a general inability to display one’s own imperfections
to others. While this form of self-protection may help an individual maintain self-esteem
and avoid criticism, it can lead to increased feelings of isolation, prevent an individual
from seeking treatment, and undermine the therapeutic alliance if and when treatment is

sought (F lett & Hewitt, 2002).

Research Questions

As a preliminary means of exploring the contribution of perfectionism in the
development and maintenance of DSH, the primary goal of the current study is to explore
the prevalence and nature of perfectionism within a DSH population compared to an
eating disorder population and comorbid eating disorder/DSH population. A secondary
goal is to explore the possibility that within a DSH population, eating disorder
population, and comorbid eating disorder/DSH population, individuals who self-identify
as survivors of childhood abuse or neglect will exhibit differential rates of interpersonal,
intrapersonal, and self-presentational dimensions of perfectionism as compared to
individuals who do not self-identify as survivors of childhood abuse or neglect. Due to
the controversies surrounding a single deﬁnition of perfectionism and the unique aspects
of this construct assessed by various perfectionism measures, multiple measures of
perfectionism will be utilized in an attempt to more fully understand the relationships
between perfectionism, DSH, and eating disorders. The following research questions will
be addressed:

1. Within a DSH population, does the prevalence of intrapersonal, interpersonal,

and self-presentational dimensions of perfectionism differ from an eating disorder

population or a comorbid eating disorder/DSH population?

2. Within DSH, eating disorder, and comorbid eating disorder/DSH populations,

do individuals who self-identify as a survivor of childhood abuse or neglect

exhibit differential rates of intrapersonal, interpersonal, and self-presentational

dimensions of perfectionism compared to individuals who do not self-identify as a

survivor of childhood abuse or neglect?

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These research questions will be addressed by examining self-oriented perfectionism,
socially prescribed perfectionism, other-oriented perfectionism, total perfectionism, and
self-presentational styles of perfectionism within the populations of interest.
Hypotheses
No differences in the prevalence of intrapersonal, interpersonal, and self-
presentational dimensions of perfectionism are expected between a DSH, eating disorder,
and comorbid eating disorder/DSH population. No hypothesis is offered regarding the

secondary goal of this study, as this goal is intended to be exploratory in nature.

11

CHAPTER 2

Literature Review

The purpose of this chapter is to review the literature relevant to the hypothesized
role of perfectionism in deliberate self-harm (DSH). The paucity of research linking
perfectionism and DSH necessitates the inclusion and integration of multiple bodies of
research drawn from the DSH, perfectionism, and eating disorders literature. Therefore,
the ﬁrst section of this chapter reviews conceptual shifts in the understanding of DSH,
diagnostic dilemmas associated with DSH, characteristics of the DSH population, and
known risk factors associated with DSH. Because perfectionism is hypothesized to
represent an additional, yet unstudied, risk factor in the development of DSH, the next
section of this chapter reviews the deﬁnitional and conceptual difﬁculties inherent in the
study of perfectionism. These difﬁculties are illustrated in the third section of this
chapter, which reviews the empirical research that has explored the role of perfectionism
in the development and maintenance of eating disorders. Fourth, the empirical,
theoretical, and diagnostic links between eating disorders and DSH will be discussed.
Established empirical links between perfectionism and eating disorders, in conjunction
with empirically established links between eating disorders and DSH, support the
importance of exploring the role of perfectionism in DSH. However, as evidenced in the
ﬁfth and ﬁnal section of this chapter, evidence for the role of perfectionism in DSH has
thus far been limited to anecdotal evidence. The present study is designed to address this

gap in the literature.

12

Deliberate Self-Harm

Deliberate self-harm (DSH), or the deliberate destruction of one’s own body tissue
that is severe enough to cause tissue damage but is performed without conscious suicidal
intent, is currently conceptualized as a maladaptive coping strategy employed to regulate
emotion and manage affect. It is considered to be a subtype of pathological self-
mutilation, separate from culturally sanctioned self-mutilation rituals and culturally
sanctioned practices such as tattooing and body piercing. Pathological self-mutilation has
been documented and discussed in the clinical literature since the inception of the ﬁeld of
psychiatry. However, empirical examination of DSH as a speciﬁc form of pathological
self-mutilation has been hampered by conceptual confusion, linguistic confusion, and
controversy surrounding the identiﬁcation of DSH behaviors as a symptom of other
psychological disorders versus a distinct syndrome in itself. A review of the current
empirical literature suggests these issues are far from resolved, and continued research is
needed in order to understand the interrelationships of previously identiﬁed risk factors in
the development of DSH, including eating disorders and perfectionism.
Conceptual Shifts in the Understanding of DSH

DSH as suicidal behavior. Initial psychological understandings of pathological

self-mutilation were problematic. Self-mutilating behaviors were conceptualized as
subtypes of suicidal behavior. Freud, for example, viewed all self-destructive behavior as
a manifestation of the thanatos, the death instinct, and self-mutilation was considered a
derivative of suicidal impulses. As a result, self-mutilation was not clinically
distinguished from suicidal behavior either conceptually or empirically. Menninger

(193 8) was the ﬁrst to hypothesize that self-mutilative behaviors served a self-protective

13

function, positing that pathological self-mutilation represented a “partial suicide” to
prevent “total suicide” by focusing the suicidal impulse on a speciﬁc part of the body.
By sacriﬁcing one part of the body, the body as a whole was saved. Menninger (193 8)
used the term focal suicide to differentiate nonsuicidal mutilation from true suicide
attempts, and further categorized self-mutilation based on the origin of the suicidal
impulse: neurosis, psychosis, organic disease, religious ceremony, and social convention.
Menninger (1938) viewed self-mutilation on a continuum ranging from psychologically
healthy, culturally approved behaviors (i.e. nail trimming, hair cutting) to pathological
self-destructive behaviors. Each form of self-mutilation was conceptualized as a
compromise formation resulting from conﬂict between the “aggressive destructive
impulses aided by the superego” and “the will to live (and love)” (Menninger, 1938, p.
285). Yet, the conceptual shift from viewing pathological self-mutilation as suicidal
behavior to viewing it as a life-sustaining, albeit paradoxical behavior, distinct from
suicide, did not appear in the empirical literature until the 19708.

DSH as a distinct syndrome. According to Favazza (1996), “The origin of the
modern concept of self-mutilation started in 1964 when Stengel wrote about the
differences between suicide and attempted suicide, which included any type of self-harm
that threatened life” (p. 270). The research that followed helped solidify the distinction
between suicide and pathological self-mutilation, and also began to examine subtypes of
pathological self-mutilation. For example, Graff and Mallin (1967) studied individuals
who engaged in wrist cutting who reported tension relief after cutting, concluding that
this group could be distinguished from suicide attempters. Similar ﬁndings were reported

by Grunebaum and Klerrnan (1967), Nelson and Grunebaum (1971), and Rosenthal,

14

 

 

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Rinzler, Walsh, & Klausner (1972). Pao (1969) labeled this phenomena “delicate self-
cutting,” and also argued that “delicate wrist-cutters” were distinct from suicide
attempters. Ross and McCay (1979) further supported the distinction, referring to self-
mutilation as “counterintentional” to suicide.
Other researchers focused on broader categories of self-harm. Kreitman et a1.
(1969) introduced the term “parasuicide” to describe both direct and indirect forms of
self-harm, such as self-mutilation and overdoses, which mimicked suicide attempts in
behavioral terms but were not intended as suicide attempts (as cited in Kreitrnan, 1977).
The term “non-fatal deliberate self-harm” was introduced by Morgan (1979) to describe
various forms of self-harm in the absence of suicidal intent. Finally, drawing on the work
of Morgan (1979), Pattison and Kahn (1983) reviewed 56 published cases of non-fatal
deliberate self-harm, excluding cases involving alcohol and drug abuse, and proposed a
deliberate self-harm syndrome as a separate diagnostic syndrome distinct from suicide.
According to Pattison & Kahn (1983):
The psychological symptoms of deliberate self-harm include 1) sudden and
recurrent intrusive impulses to harm oneself without the perceived ability to
resist; 2) a sense of existing in an intolerable situation which one can neither c0pe
with nor control; 3) increasing anxiety, agitation, and anger; 4) constriction of
cognitive-perceptual processes resulting in a narrowed perspective on one’s
situation and personal alternatives for action; 5) a sense of psychic relief after the
act of self-harm; and 6) a depressive mood, although suicidal ideation is not

typically present. (p. 867)

15

Drawing on previous research, Pattison and Kahn (1983) proposed a classiﬁcation
system for identifying DSH within a larger context of self-destructive behaviors based on
three variables: direct versus indirect forms of self—destruction, degree of lethality, and
repetitiveness. Direct self-destruction implies conscious intent to harm oneself with an
awareness of the consequences of one’s actions. In contrast, indirect self-destruction
implies no conscious intent, with either no awareness of the consequences of one’s
actions or a disregard for possible consequences (Pattison & Kahn, 1983). Pattison and
Kahn (1983) state that direct self-destructive acts typically occur within a short time
frame, whereas indirect self-destruction, such as substance dependence, typically occurs
across a sustained time period. The lethality variable indicates the probability of death
resulting from the self-destructive act, ranging from a low probability to a high
probability. Finally, the repetition variable distinguishes between single episodes of self-
destructive behavior versus repetitive or multiple episode behaviors. Within this
classiﬁcation schema, Pattison and Kahn (1983) describe DSH as a disorder of impulse
control that represents “a distinctive class of self-destructive behavior, which is
distinguished by direct self-harm behavior, with low lethality, in a repetitive pattern” (p.
870). Favazza (1996) credits Pattison and Kahn’s (1983) proposed DSH syndrome as the
“concept that marks the beginning of modern interest in self-mutilation” (p. 252).

DSH as a subtype of pathological self-mutilation. Expanding on the DSH
syndrome prototype described by Pattison and Kahn (1983), F avazza and colleagues
(F avazza &Rosenthal, 1990; Favazza & Rosenthal, 1993; Favazza & Simeon, 1995)
outlined a more complex classiﬁcation of direct, nonsuicidal self-harm under the rubric

of self-mutilation. The two major categories of self-mutilation are described as culturally

16

sanctioned self-mutilation (i.e. cultural rituals and practices) and deviant-pathological
self-mutilation. Deviant-pathological mutilation is divided into three types based on
degree of tissue damage: major, stereotypic, and moderate/superﬁcial.

Major self-mutilation represents a category of behaviors which are encountered
infrequently but cause signiﬁcant tissue damage. Examples include castration, limb
amputation, and eye enucleation (Favazza & Rosenthal, 1993). Although not associated
with any speciﬁc mental disorder, psychotic individuals preoccupied with religion and/or
sexuality appear to be at a higher-risk for major self-mutilation.

Stereotypic self-mutilation, in contrast, is “monotonously repetitive and may even
have a rhythmic pattern” (F avazza, 1996, p. 237). The most commonly cited example of
stereotypic self-mutilation is head banging. Stereotypic self-mutilation is commonly
observed as a symptom or associated feature of mental retardation, autism, Lesh-Nyham
syndrome, deLange syndrome, Retts disorder, neurocanthosis, Tourette syndrome, and
obsessive compulsive disorder (Favazza & Rosenthal, 1993; Favazza, 1996). Stereotypic
self-mutilation is often referred to as self-injurious behavior (SIB) in the empirical
literature, and appears to lack any symbolic meaning in regards to emotional expression.
Moderate/superﬁcial self-mutilation, on the other hand, represents the third category of
deviant-pathological self-mutilation and is typically viewed as a symbolic means of
emotional expression related to tension reduction and emotional regulation. Common
moderate/superficial self-mutilation behaviors include low lethality cutting, burning,
skin carving, skin picking, and skin scratching.

Moderate/superﬁcial self-mutilation is divided into three subtypes based on

repetition of the behaviors: compulsive, episodic, and repetitive (Favazza & Rosenthal,

17

1993; F avazza, 1996). As implied by the terminology, compulsive moderate/superﬁcial
self-mutilation is repetitive and ritualistic in nature; episodic moderate/superﬁcial
mutilation occurs occasionally; and repetitive moderate/superﬁcial self-mutilation occurs
repeatedly over a sustained period of time. Speciﬁc examples of compulsive self-
mutilation include hair pulling and other psychoderrnatological conditions. Severe
symptoms may be treated by a dermatologist or family physician, but individuals with
mild symptoms rarely seek professional help (Favazza, 1996). Episodic self-mutilation
differs from repetitive self-mutilation in that individuals who engage in
superﬁcial/moderate self-mutilation on an occasional basis tend not to incorporate self-
injury as a component of self identity and do not become preoccupied with self-injuring
(Favazza, 1996). In contrast, individuals engaging in repetitive self-mutilation often
describe an addictive quality to their self-injury. Repetitive self-mutilation, as described
by Favazza and colleagues (Favazza & Rosenthal, 1993; Favazza, 1996), is consistent
with the DSH syndrome prototype described by Pattison and Kahn (1983). In fact,
Favazza and Rosenthal (1993) also argue for a distinct diagnosis for those individuals
who engage in repetitive superﬁcial/moderate self-mutilation. They proposed a
Repetitive Self-Mutilation (RSM) syndrome to be listed on Axis I in the American
Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders, under
“impulse control disorder not otherwise speciﬁed.”

In summary, although a conceptual shift in understanding pathological self-
mutilation had emerged by the 1970s, multiple terms had been introduced to describe the
same phenomena, including: focal suicide, delicate self-cutting, parasuicide, symbolic

wounding, local self-destruction, intentional injury, self-injurious behavior, self-abuse,

l8

deliberate self-harm, and episodic or repetitive self-mutilation (Favazza, 1996). Many of
these terms continue to be used throughout the literature, often interchangeably, to
describe a continuum of self-destructive behaviors ranging from minor tissue damage
requiring no medical attention to attempted suicide. The wide variation in how these
terms are operationally deﬁned and the inconsistent use of different terms creates
difﬁculties when attempting to compare results across studies. Therefore, for the sake of
clarity, the term deliberate self-harm will be used throughout the remainder of the
literature review to indicate deliberate destruction or alteration of body tissue severe
enough to cause tissue damage (i.e. scarring), but performed without suicidal intent.
This term incorporates Favazza and Rosenthal’s (1993) deﬁnition of episodic and
repetitive superﬁcial/moderate self-mutilation without the negative connotation so often
associated with the behavior. The term excludes individuals who self-injure to psychotic
disorders or organic disorders such as developmental disabilities.
Diagnostic Dilemmas Associated with Deliberate Self-Harm

Dtﬂerences between DSH and suicidal behavior. The issue of a separate
diagnostic category for DSH remains unresolved, in part, because DSH has historically
been viewed as a variant of suicidal behavior, and is often argued to be a feature of
various Axis I and Axis II disorders rather than a distinct disorder in itself. While it
should be noted that individuals who engage in DSH are at an increased risk for suicide
(Conterio & Lader, 1998; Favazza & Rosenthal, 1983; Kahn & Pattison, 1983), a
substantial body of research supports the distinction between suicidal behavior and DSH.
Walsh and Rosen (1988) summarize this distinction by contrasting 10 common

characteristics shared by suicidal individuals, as outlined by Shneidman (1985), with 10

19

common characteristics shared by individuals who engage in DSH. The distinctions are
as follows (Walsh & Rosen, 1998): 1) Suicide is viewed as a means to escape
unendurable psychological pain; acts of DSH are a means to reduce intermittent,
escalating psychological pain to a more endurable level. 2) Suicidal acts typically arise
from frustrated psychological needs; acts of DSH typically arise from a low frustration
tolerance in combination with deferred psychological needs. 3) Suicide represents a
ﬁnal solution to problems with no foreseeable solution; DSH represents a temporary
solution to alleviate distress immediately. 4) Suicide leads to a cessation of
consciousness; DSH leads to an alteration in consciousness, often helping an individual
return from a state of depersonalization or dissociation. 5) The primary emotional states
associated with suicide include hopelessness and helplessness; the primary emotional
states associated with DSH involve intrapersonal and interpersonal isolation. 6) Suicide
is associated with feelings of ambivalence; DSH is associated with feelings of
resignation. Individuals engaging in DSH often view their self-harm as a necessary
survival tool. 7) Constriction and dichotomous thinking characterizes the cognitive
states associated with suicide; fragmentation, including dissociation and
depersonalization, characterizes the cognitive state of self-banners. 8) Among
completed suicides, 80% have communicated their intention prior to the act
(Schneidman, 1985, as cited in Walsh & Rosen, 1998). In contrast, DSH is typically not
made known to others until the act has been committed, and may be employed as a means
of eliciting desired responses from others. 9) Suicidal acts function as a means of
escape; DSH acts serve the functions of psychological reintegration, social

reinvolvement, and return to emotional equilibrium. 10) Finally, while both suicide and

20

DSH may represent extensions of other coping responses evident in one’s life, DSH is
adaptive in that it is life-sustaining, whereas suicide precludes the further development of
alternative coping strategies. The difference in functions of DSH and suicidal behavior
have been further supported by qualitative studies that report individuals’ perceived
reasons for engaging in DSH. The qualitative evidence clearly supports the hypothesis
that DSH does not represent suicidal behavior, but instead serves as a maladaptive coping
strategy employed to regulate emotion and reduce tension (Conterio & Lader, 1998;
Himber, 1994; Shearer, 1994; Strong, 1998).

DSH and personality disorders. The distinction between suicide and DSH is now
widely accepted and acknowledged. However, instead of a distinct diagnosis, DSH is
often viewed as an associated feature of personality disorders, especially borderline
personality disorder, a diagnosis which has also become controversial (Farber, 2000).
“Recurrent suicidal behaviors, gestures or threats, or self—mutilating behavior” is one of
the nine diagnostic criteria for borderline personality disorder, and constitutes the only
reference to DSH in the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition (American Psychological Association, 1994, p. 654). The relationship between
DSH and borderline personality disorder has been supported in the literature by numerous
studies (Brodsky et al., 1995; Dulit, Fryor, Leon, Brodsky, & Frances, 1994; Sansone,
Wiederman, & Sansone, 1998; Zweig-Frank et al., 1994), but recognizing DSH
exclusively as a symptom of borderline personality disorder ignores the wide range of
other Axis I and Axis II disorders also associated with DSH in the absence of borderline
personality disorder (Favazza & Rosenthal, 1993). DSH has been documented among

individuals diagnosed with histrionic personality disorder, narcissistic personality

21

disorder, dissociative disorders, mood disorders, anxiety disorders (including PTSD and
obsessive compulsive disorder), and eating disorders.
Characteristics of the DSH Population

While an argument has been made that the incidence of DSH is on the rise
(Pipher, 1994), there is a paucity of epidemiological data regarding the DSH population.
Given the secretive nature of the behavior, reported increases in DSH rates may reﬂect a
growing awareness and identiﬁcation of the phenomena rather than an actual increase in
the number of individuals engaging in DSH behaviors. Currently, the “typical proﬁle” of
a self-injurer is based primarily on the characteristics of individuals seeking treatment.
The “typical” self-harmer seen in treatment is a middle class or upper middle class
Caucasian female, of average or above average intelligence with a history of trauma
(Conterio & Lader, 1998; Miller, 1994; Selekman, 2002).

Consistent with the general use of psychological services, approximately two-
thirds of individuals seeking treatment for DSH are female (Favazza & Conterio, 1989;
Simeon & Hollander, 2001). Several studies indicate DSH is more common among
women than men (Boudewyn & Liem, 1995; Favazza & Rosenthal, 1990; Suyemoto,
1998). Yet, other studies report the frequency and method of DSH is not signiﬁcantly
associated with gender (Gratz, 2001; Pattison & Kahn, 1983).

Reported gender differences may be a function of the context from which study
participants are drawn. The majority of studies examining DSH among males focus on a
prison population, while the clinical research literature draws heavily on the use of
female participants (Turner, 2002). Given that males are more likely to externalize

aggressive impulses and act out, while females tend to internalize and direct aggression

22

inward, females may indeed be at greater risk for chronic, repetitive DSH, whereas males
appear to be at greater risk for major acts of self-mutilation and completed suicide
(Barnes, 1985). However, the multiple deﬁnitions of DSH used within the empirical
literature, combined with the lack of behaviorally-based, empirically validated
instruments assessing DSH prevent ﬁrm conclusions from being drawn regarding gender
differences in DSH.

Research indicates that DSH typically begins in adolescence or early adulthood,
with initial acts often occurring around the time of puberty (F avazza, 1998; Favazza &
Rosenthal, 1993; Pattison & Kahn, 1983). Among females, initial acts of DSH often
coincide with the onset of menstruation (Nichols, 2000; Rosenthal etal., 1972). In fact,
some evidence suggests girls who reach puberty early are at greater risk for DSH (Eccles,
Barber, Josefowiew, Malenchuk, & Vida, 1999). The frequency and intensity of DSH
acts usually waxes and wanes but may become habitual and assume an addictive-like
quality (Favazza & Rosenthal, 1993). Although isolated incidences of DSH may occur
across the life span, the frequency of DSH usually decreases by the late twenties and
chronic DSH is uncommon after age 35 (van der Kolk, Perry, & Herman, 1991). FavaZza
& Rosenthal (1993) indicate that many individuals cease to employ DSH as a coping
strategy after 10 to 15 years of self-harming.

Individuals who engage in DSH are at an increased risk for suicide, but suicide
attempts typically occur by means other than DSH (i.e. overdosing), and only a small
percentage complete suicide (Conterio & Lader, 1998; Favazza & Rosenthal, 1993; Kahn
& Pattison, 1983). The clinical course of DSH typically involves multiple episodes of

low lethality using multiple methods; approximately 7 5% of individuals employ more

23

than one method of DSH (Conterio & Lader, 1989). In one study of habitual self-
harmers, Favazza and Conterio (1988) found the most common methods of DSH, in order
of prevalence, were cutting, burning, self-hitting, interference with wound healing, hair
pulling, and bone breaking. Other methods include scratching until skin abrasions occur,
facial skinning, head banging, and ingestion of sharp objects (Conterio & Lader, 1998).

According to Conterio and Lader (1998), common characteristics among the DSH
population include the following: 1) “Difﬁculties in various areas of impulse control, as
manifested in problems with eating behaviors or substance abuse;” 2) “A history of
childhood illness, or severe illness or disability in a family member;” 3) “Low capacity to
form and sustain stable relationships;” 4) “Fear of change;” 5) “An inability or
unwillingness to take adequate care of themselves;” 6) “Low self-esteem, coupled with a
powerful need for love and acceptance from others;” 7) “Childhood histories replete with
trauma or signiﬁcant parenting deﬁcits, which lead to difﬁculties internalizing positive
nurturing;” and 8) “Rigid all-or-nothing thinking” (pp. 138-140). These characteristics
are reﬂected in the identiﬁed risk factors for DSH.
Risk Factors in the Development of DSH

Multiple risk factors have been implicated in the development of DSH, but the
majority of empirical research has focused on speciﬁc historical factors related to
interpersonal distress. In contrast, proximal risk factors have received less attention.
Because DSH is of heterogeneous etiology, continued research is needed not only to
determine the relative contribution of each identiﬁed risk factor, but also to investigate

how these risk factors may interact to increase the risk for DSH behaviors.

24

Child abuse and trauma. Signiﬁcant emphasis has been placed on the etiological
role of child abuse in DSH. Child abuse can be deﬁned as “any behavior directed toward
a child by a parent, guardian, caregiver, other family member, or other adult, that
endangers or impairs a child’s physical or emotional health and development” (National
Council on Child Abuse and Family Violence, 2000). The four major categories of child
abuse include physical abuse, sexual abuse, emotional abuse, and neglect.

Research has consistently demonstrated a link between different types of
childhood abuse and deliberate self-harm (Romans, Matin, Anderson, Herbison, &
Mullen, 1995; Shapiro, 1987; Simeon & Hollander, 2001). DSH behaviors have been
noted in abused and neglected children as young as two to ﬁve years of age (Rosenthal &
Rosenthal, 1984). In an early study by Green (1978), 41% of 59 maltreated children
studied engaged in DSH behaviors. Simpson and Porter (1981), in a study of hospitalized
self-harmers, age 5 to 19, reported that 13 out of 20 subjects had a history of physical
abuse and 9 out of 20 reported sexual abuse. Among adolescents, an age most associated
with the onset of DSH, the relationship between abuse and DSH is even more striking.
For example, Kendall-Tackett, Williams, and Finkelhor (1993) reviewed studies of
adolescent sexual abuse survivors and found that DSH was a common problem in this
population. DSH was reported in 71% of the adolescent sexual abuse survivors.
Furthermore, Walsh and Rosen (1988) reported that adolescent self-harmers were
signiﬁcantly more likely than a clinical comparison group of adolescent non-self-harmers
to have a history of childhood sexual or physical abuse. Although the above studies are
limited by small sample sizes, larger studies involving older subjects have yielded similar

results. In one of the largest studies of DSH (240 subjects), 29% of subjects reported

25

both sexual and physical abuse, 17% reported only sexual abuse, and 16% reported only
physical abuse (Favazza & Conterio, 1989).

Similarly, van der Kolk et a1. (1991) found that childhood sexual abuse, childhood
physical abuse, and neglect were strongly associated with self-destructive behavior in
adulthood, including both DSH and suicide attempts. Among the DSH group studied,
79% reported trauma histories involving at least one of the following types of traumas:
witnessing domestic violence, physical abuse, and sexual abuse (van der Kolk et al.,
1991). The relationship between childhood physical abuse and DSH has been reported in
additional studies (Simpson & Porter, 1981; Walsh & Rosen, 1998), but interestingly,
Van der Kolk et a1. (1991) reported that childhood sexual abuse survivors were more
likely than physical abuse survivors to engage in self-harm.

Given the multitude of studies linking child abuse to DSH, therapists may be
tempted to conclude that most individuals who engage in DSH come from an abusive
background. Yet, several researchers have found no evidence of childhood sexual or
physical abuse among individuals engaging in DSH (Brodsky et al., 1995; Zweig-Frank
et al., 1994). Selekrnan (2002) cautions that, particularly among adolescents, the
presence of DSH does not necessarily indicate a history of trauma or abuse. Furthermore,
not all childhood abuse survivors engage in DSH. For instance, estimates of the
prevalence of DSH among intrafamiliar sexual abuse survivors range ﬁ'om 17% (Briere
& Zaidi, 1989) to 58% (de Young, 1982). Based on a review of studies dating from 1988
to 1998, Santa Mina and Gallop (1998) concluded that “the link between trauma and self-
harm or suicide is strongest when the abuse has been of long duration, the perpetrator has

been known to the victim, and force and penetration have occurred” (p. 798). A study

26

conducted by Turell and Ainsworth (1998) found ﬁve variables that differentiated sexual
abuse survivors who self-harmed from abuse survivors who did not self-harm. Sexual
abuse survivors who self-banned evidenced 1) greater dissociation/depersonalization; 2)
somatization and increased medical concerns; 3) greater body image distortions; 4)
increased history of anorexia and/or bulimia; and 5) an increased likelihood of physical
and/or physiological abuse in one’s family of origin.

The majority of studies examining the relationship between childhood abuse and
DSH are limited by inconsistent deﬁnitions of abuse, self-harm, and, in general, small
sample sizes and a reliance on retrospective victim reports of abuse. However, despite
methodological limitations, the empirical evidence supports the etiological role of
childhood abuse in the later development of DSH. The lack of a conceptual framework
in most of the studies further impedes the current understanding of the relationship
between childhood abuse and DSH; whether childhood abuse represents a general risk
factor or speciﬁc risk factor remains unknown. Several theorists and researchers have
postulated that childhood abuse alone does not predicate DSH; rather, it is childhood
abuse in the context of pathological family relationships that predisposes individuals to
adopt DSH as a coping strategy (F avazza, 1989; Selekman, 1992; Tatum & Whittaker,
1992). For example, van der Kolk et a1. (1991) indicate that while histories of childhood
sexual or physical abuse are signiﬁcantly associated with initiation of DSH, disruptions
in attachment, such as neglect, appear to play a role in the maintenance of the behavior.
Yet, compared to childhood sexual and physical abuse, the roles of neglect and emotional
abuse, as well as other potential risk factors, have received less systematic empirical

attention.

27

Dissociation. Dissociation has been identiﬁed as an important proximal risk
factor for DSH. Although the defense mechanism of dissociation is commonly
associated with childhood abuse histories, dissociative processes can occur in the absence
of an abuse history. Brodsky et al. (1995) reported a strong association between
dissociation and DSH independent of child abuse history. According to Favazza (1989),
individuals who engage in DSH “often report that emotional deadness, the diminished
ability to experience normal sensations, estrangement from the environment, and an
altered perception of time result in feelings of unreality” (p. 139). DSH represents a
means to manage dissociative processes. It can be used either as a grounding technique
to prevent dissociation, or used to allow one to enter a dissociative state to escape
emotional pain (Turner, 2002).

Childhood Illness and Surgeries. An early history of surgical procedures and
medical illnesses are common in the DSH population. Rosenthal et a1. (1972) reported
the majority of self-harmers experienced serious illnesses, surgeries, or accidents before
age 12; no similar experiences were reported within a matched control group. Rosenthal
et a1. (1972) therefore concluded that the experience of early surgical procedures and
medical interventions may serve as prototypes for later acts of DSH. Similarly, Walsh &
Rosen (1988) reported that adolescent self- harmers were signiﬁcantly more likely than
non self-harmers to have experienced major surgery during childhood, or suffered from a
chronic or serious childhood illness. Walsh & Rosen (1988) suggested that “body image
problems associated with childhood illness serve as a foundation for profound body

alienation in [self-harming] adolescents” (p.63).

28

Body alienation. Although the role of trauma associated with childhood illness or
surgery is less clear than the role of childhood abuse, body alienation may represent a
common factor underlying various types of trauma that predisposes an individual to
target one’s own body for self-inﬂicted harm. Friedman, Glasser, Laufer, Laufer, and
Whol (1972) hypothesized that the concept of body alienation, or the feeling that one’s
body is a separate entity from one’s real self, may explain why some individuals target
their own body for self-harm. Body alienation is a common characteristic among abused
children (Goodwin, Simms, & Bergman, 1979). A link between childhood illness and
body alienation has also been established (Hughes, 1982).

Abrupt body changes that occur during puberty may increase a sense of body
alienation and reinforce the feeling of loss of control over one’s own body, especially for
individuals with a history of traumatic intrusions on the body due to abuse, illness, or
surgeries (Walsh & Rosen, 1988). DSH is often viewed as an attempt to reestablish a
sense of bodily control (Conterio & Lader, 1998; Farber, 2000; Favazza, 1989; Favazza
& Rosenthal, 1993). According to Farber (2000), “Girls are more prone than boys to
body alienation in adolescence because their attitudes toward their bodies are more
readily inﬂuenced by powerful, complex, and confusing bodily experiences” (p. 297).
Thus, the concept of body alienation provides partial insight into the development of
DSH during adolescence and the common belief that DSH is more common among
females than males.

DSH represents one method to express feelings of body alienation. In fact, Walsh
& Rosen (1988) found that self-harming adolescents were signiﬁcantly more likely than

adolescents who did not self-harm to exhibit carelessness in their physical appearance,

29

distress over sexual identity, and to have eating disorders, each of which was
hypothesized to be an expression of feelings of body alienation. Among the variables
studied, the strongest correlation was found between DSH and eating disorders (Walsh &
Rosen, 1988). The relationship between DSH and eating disorders will be discussed in
greater detail at a later point in this chapter.

Disruptions in parent-child attachment. Disruption in the parent-child
relationship during childhood is another common characteristic among the DSH
population. Childhood abuse, chronic childhood illness, and early hospitalizations
certainly have the potential to negatively inﬂuence child-parent bonds. Residence in a
total care institution, loss of a parent, parental alcoholism, and parental depression
represent additional identiﬁed risk factors that suggest the etiological role of disrupted
parent-child relationships (Briere & Gill, 1998; Walsh & Rosen, 1988). Yet, only one
empirical study has speciﬁcally examined the quality of parent-child attachment as it
relates to later development of self-harm. Gratz, Conrad, & Roemer (2202) found that
insecure parent-child attachment was signiﬁcantly associated with frequency of DSH
within a nonclinical college population. Related studies, while limited, imply that quality
of parent-child attachment as an etiological factor in DSH deserves increased attention.
For example, Romans et a1. (1995) reported a signiﬁcant association between DSH and
interpersonal problems in one’s family of origin. Additionally, Favazza and Conterio
(1989) reported that the majority of self-banners have been raised by families
characterized by anger and double messages, where expression of feelings are
discouraged and presenting a strong appearance is valued. According to Conterio and

Lader (1998), “The common ties that bind these [family] experiences are an atmosphere

30

of severe anxiety and the inability of the parents to respond appropriately to the child’s
emotional needs” (p. 49).

In studies of nonhuman primates, self-injurious behavior was found to be a
common reaction to disruptions of parental caretaking and attachment (Mineka & Suomi,
1978, as cited in van der Kolk et al., 1991). Similarly, adults who engaged in DSH, who
had also experienced disruptions in the development and maintenance of parental
attachment relationships, were found to have difﬁculty controlling their DSH behaviors,
and experienced difﬁculty taking advantage of interpersonal resources (van der Kolk et
al., 1991). Moreover, Linehan (1993) has noted that the majority of adults who
deliberately self-harm come from invalidating home environments, characterized by
insecure attachment relationships. As a result, children who come from these
environments internalize the way that they have been treated and develop a negative self-
view. To date, the relationship between attachment and DSH has existed almost
exclusively at a theoretical level. Empirical evidence speciﬁcally linking quality of
parent-child attachment relationships and DSH is lacking.

In review, research has identiﬁed multiple risk factors associated with DSH.
Proximal risk factors have been minimally addressed, although a strong argument has
been made regarding the role of body dissatisfaction, body alienation, and dissociation.
The majority of research has focused on speciﬁc historical factors that appear to increase
the likelihood of DSH, including child abuse and trauma, chronic childhood illness, early
surgeries or hospitalizations, and residence in total care institutions. Parental alcoholism
has also been identiﬁed as a contributing risk factor. Theoretically, each of these

identiﬁed risk factors has the potential to negatively impact the development of secure

31

child-parent attachment, thus impacting the characterological development of the child.
Disruptions in parent-child attachment relationships are assumed to play an etiological
role in the development of DSH, but the empirical literature has minimally addressed this
theoretical proposition.

Perfectionism

Case reports and anecdotal evidence suggest perfectionism represents an
additional characterological risk factor in the development of DSH which has failed to
receive empirical attention (Levenkron, 1998; Strong, 1998). The clinical importance of
investigating perfectionism within this population is supported by research:
Perfectionism has demonstrated a signiﬁcant association with difﬁculties establishing a
strong working alliance and poor treatment outcome (Blatt & Zuroff, 2002). Strong
(1998) states, “Self-injurers are often bright, talented, creative achievers—perfectionists
who push themselves beyond all human bounds, people-pleasers who cover their pain
with a happy face” (p. 18).

The relationship between perfectionism and DSH has not been studied
empirically, but high comorbid rates of DSH and eating disorders, in conjunction with the
empirically established relationship between perfectionism and eating disorders, suggests
perfectionism may represent a characterological vulnerability in the development of
DSH. As will be evident in the following review of the perfectionism literature, it must
ﬁrst be acknowledged that perfectionism represents an inherently complex psychological
construct, and various researchers have employed different conceptualizations of the

construct throughout the literature base.

32

Defining Perfection ism

Historically, perfectionism has been deﬁned in the psychological literature as a
unidimensional construct involving irrational beliefs; early literature heavily emphasized
the negative aspects of perfectionism. For example, Burns (1980) described
perfectionists as “those whose standards are beyond reach or reason, people who strain
compulsively and unremittingly toward impossible goals, and who measure their own
worth entirely in terms of productivity and accomplishment” (p. 34). Recently, however,
the psychological literature has recognized positive aspects of perfectionism as well, and
also recognized that perfectionism includes interpersonal components in addition to
intrapersonal components.

The complex, multidimensional nature of perfectionism is reﬂected in the lack of
a consensus regarding an operational deﬁnition for the construct. Various terms have
been introduced to delineate psychologically healthy and psychologically unhealthy
aspects of perfectionism, including normal versus neurotic perfectionism (Hamachek,
1978), positive versus negative perfectionism (Terry-Short et al., 1995), and adaptive
versus maladaptive perfectionism. Yet, attempts to distinguish psychologically healthy
and psychologically unhealthy aspects of perfectionism has only fueled the deﬁnitional
debate.

Hewitt argues that deﬁning perfectionism in terms of adaptiveness and
maladaptiveness represents an oversimpliﬁcation of the construct (as cited in Benson,
2003). Similarly, Frost argues that differentiating perfectionists into two categories based

on the presumed adaptiveness or maladaptiveness of perfectionistic traits fails to take into

33

the account the role of contextual factors; contextual factors may help determine whether
speciﬁc perfectionistic behaviors are adaptive or maladaptive (as cited in Benson, 2003).
Given the continued debate over the qualitative differences between the two types of
perfectionists, several researchers have taken an alternative approach to conceptualization
and examined perfectionism in terms of intrapersonal and interpersonal dimensions, thus
allowing consideration of contextual factors. Empirical evidence has emerged that
interpersonal and intrapersonal dimensions of perfectionism differentially relate to
psychological distress (Hewitt & Flett, 1991).
Multidimensional Conceptualizations of Perfectionism

Much of the multidimensional perfectionism research has been derived from the
conceptualizations of perfectionism put forth by two separate groups of researchers.
Hewitt & F lett (1991) delineate one intrapersonal dimension of perfectionism-self-
oriented perfectionism--and two interpersonal dimensions of perfectionism—other-
oriented perfectionism and socially prescribed perfectionism—based on the source and
target of perfectionistic expectations. Self-oriented perfectionism involves excessively
high standards of performance that arise from and are directed toward oneself. In
general, self-oriented perfectionism has been considered adaptive in nature. However,
recent empirical studies have shown some support for a diathesis-stress model of
perfectionism based on the hypothesis that adaptive aspects of perfectionism can become
maladaptive under stressful conditions, especially when individuals are faced with ego-
involving situations that threaten the self (Flett & Hewitt, 2002). In other-oriented
perfectionism, others are the target for one’s excessively high standards and

perfectionistic expectations. In contrast, socially prescribed perfectionism involves the

34

belief that others hold oneself to excessively high standards and expect perfection.
Other-oriented and socially prescribed perfectionism have generally been presented as
maladaptive dimensions of perfectionism within the clinical literature. Socially
prescribed perfectionism has been reported to have the broadest association with
psychopathology (Enns & Cox, 2002), while other-oriented perfectionism has been
linked to indexes of interpersonal hostility (Hill, McIntre, & Bacharach, 1997).

Frost, Martin, Lahart, & Rosenblate (1990), while not explicitly outlining an
interpersonal dimension of perfectionism, include parental expectations and parental
criticism as two important interpersonal components in the measurement of
perfectionism. Key intrapersonal components, as identiﬁed by Frost et al. (1990), include
excessively high personal standards, personal emphasis on order and organization,
heightened concern over personal mistakes, and pervasive doubts about one’s actions.

Complementary to the aforementioned conceptualizations of perfectionism, self-
presentational perfectionism is beginning to receive empirical attention as a clinically
relevant interpersonal aspect of perfectionistic behavior. Self-presentational
perfectionism refers to a perfectionist’s need to actively display a ﬂawless image in
interpersonal situations and avoid disclosures of imperfection. In the context of therapy,
self-presentational perfectionism has the potential to undermine the working alliance and
resulting treatment progress due to the client’s reluctance to disclose personal aspects of
the self (Flett & Hewitt, 2002).

Table 1 summarizes the similarities and differences among the multitude of

conceptualizations of perfectionism that appear throughout the literature.

35

Table 1

Conceptualizations of Perfectionism

 

Term

Deﬁnition

 

Normal perfectionism

Neurotic perfectionism

Positive perfectionism

Negative perfectionism

Self-oriented perfectionism"

Other-oriented perfectionism“

Socially prescribed perfectionism“

Adaptive perfectionism

Maladaptive perfectionism

Perfectionistic self-presentation"l

Striving for reasonable or realistic standards; results

in self-satisfaction and increased self-esteem

Striving for excessively high self-standards; driven by fear
of failure and fear of disappointing others

Perfectionistic behavior arising from positive
reinforcement and approach tendencies

Perfectionistic behavior arising from negative
reinforcement and avoidance tendencies

Excessively high personal standards originating from

and directed toward the self

Excessively high standards for and perfectionistic
expectations of others
Belief that others hold oneself to excessively high standards
Positive perfectionistic behaviors that include high personal
standards, organization, self-oriented perfectionism, and
other-oriented perfectionism

Negative perfectionistic behaviors that include socially-
prescribed perfectionism, concern over mistakes, doubts
about actions, parental expectations, and parental criticism
Need to actively display a ﬂawless image in interpersonal

situations and avoid disclosures of imperfection

 

Note. Conceptualizations of perfectionism addressed in the current study indicated by ‘2

36

In summary, perfectionism is currently understood as a multidimensional
construct with signiﬁcant implications for psychological health. Although multiple
conceptualizations of perfectionism exist throughout the empirical literature, it is widely
accepted that perfectionism represents a relatively stable personality trait that can serve as
a vulnerability to psychological distress. While case reports and anecdotal evidence
suggest that perfectionism is a vulnerability factor in DSH, this link has yet to be studied
empirically. Related empirical evidence, however, suggests the probability of this
relationship. Speciﬁcally, perfectionism has been implicated in the development and
maintenance of eating disorders, and a high comorbidity of eating disorders and DSH has
been documented.

Perfectionism and Eating Disorders

Although perfectionism has been linked to a wide range of healthy and unhealthy
psychological indexes, the following section focuses exclusively on empirical ﬁndings
relevant to the role of perfectionism in the development and maintenance of eating
pathology. First, limitations of the early empirical research examining the relationship
between perfectionism and eating disorders will be reviewed. The mixed results obtained
from early studies relying on a unidimensional conceptualization of perfectionism
provide compelling evidence for the need to study perfectionism from a multidimensional
perspective in order to fully understand the relationship between perfectionism and eating
disorders. Second, studies employing multidimensional conceptualizations of
perfectionism will be reviewed. Separate consideration will be given to studies
distinguishing between adaptive and maladaptive perfectionism and studies which

examine intrapersonal and interpersonal dimensions of perfectionism. Finally, evidence

37

will be presented that perfectionistic self-presentation constitutes a clinically relevant
aspect of perfectionism in the treatment of individuals with eating disorders.
Limitations of Early Research Examining Perfectionism in Eating Disorder Populations
Early research examining the relationship between perfectionism and eating
pathology concentrated on the prevalence of perfectionistic tendencies among eating
disorder populations, and numerous studies concluded that individuals with eating
disorders display elevated levels of perfectionism compared to non-eating disordered
populations (Bastiani, Rao, Weltzin, & Kaye; Bourke, Taylor, & Crisp, 1995; Garner,
Olmstead, & Polivy, 1983a, 1983b; Rosch, Crowther, & Graham, 1991; Srinivasagarn et
al., 1995; Thompson, Berg, & Shatford, 1987 ; Toner, Garﬁnkel, & Garner, 1986).
Alternatively, other researchers found no evidence of elevated perfectionism scores
among eating disorder populations when compared to non-eating disorder populations.
For example, Garner et al. (1984) reported no signiﬁcant differences in perfectionism
between a weight-preoccupied control group and a group of individuals diagnosed with
anorexia nervosa. Blouin et al. (1989) found no signiﬁcant differences in perfectionism
among individuals diagnosed with bulimia and individuals diagnosed with diabetes, but
perfectionism scores were elevated among bulimics compared to normal controls.
Finally, Hurley et a1. (1990) found no signiﬁcant differences in perfectionism among a
clinical eating disorder group and a group of individuals diagnosed with other
psychological disorders, suggesting elevated perfectionism scores may be characteristic
of general psychopathology and not speciﬁc to eating disorder populations. The mixed
results obtained from the above studies are made more difﬁcult to understand because of

the atheoretical nature of the studies. Additional limitations include the use of

38

correlational data and overreliance of the 6-item Perfectionism subscale embedded within
the Eating Disorders Inventory (EDI; Garner, Olmstead, & Polivy, 1983a; Garner, 1991).

The Perfectionism subscale of the EDI (EDI-P) has been historically viewed as a
unidimensional measure of global, trait perfectionism that exclusively focuses on
cognitive and behavioral aspects of self-directed, or self-oriented perfectionism (Ackard
& Peterson, 2001). Joiner and Schmidt (1995), however, established that the EDI-P is
actually a multidimensional measure. Using conﬁrmatory factor analyses, Sherry,
Hewitt, Besser, McGee, and F lett (2003) supported the multidimensional nature of the
EDI-P, concluding that among the six items contained in the subscale, 3 items measured
self-oriented perfectionism and 3 items measured socially prescribed perfectionism.
Structural equation modeling demonstrated that self-oriented perfectionism (SOP) and
socially prescribed perfectionism (SPP), as assessed by the EDI-P, independently related
to eating disorder symptomatology (Sherry et al., 2003). Interestingly, Sherry et a1.
(2003) also found that for women and not men, moderational analyses revealed that the
predictive value of EDI-SOP for eating disorder symptoms was dependent on the level of
EDI-SPF.

This ﬁnding highlights two signiﬁcant limitations of previous studies relying on
the EDI-P with disregard for the multidimensional nature of perfectionism. First, when
utilized as a unidimensional assessment of perfectionism, the EDI-P may confound
results because the intrapersonal and interpersonal dimensions of perfectionism are
collapsed into a singular, global measurement of perfectionism. Second, this ﬁnding
suggests that correlational analyses alone may not be sophisticated enough to

discriminate the true contribution of perfectionism in the development and maintenance

39

of eating pathology. For example, in testing a diathesis-stress model of bulimia using the
EDI-P, Joiner, Heatherton, Rudd, and Schmidt (1997) found that self-esteem moderated
the interactional effects of perfectionism and body dissatisfaction in the development of
bulimic symptoms. In other words, it is not only reasonable to assume that various
psychological factors moderate or mediate the relationship between perfectionism and
eating disorders, but as suggested by the ﬁndings of Sherry et a1. (2003), intrapersonal
and interpersonal dimensions of perfectionism may interact to predict eating pathology.
There is limited data supporting the latter hypothesis, as the speciﬁc relationships
between different dimensions of perfectionism and eating disordered behavior have only
recently begun to receive empirical attention with the advent of comprehensive
multidimensional perfectionism measures.

An additional and ﬁnal limitation of studies using the EDI-P was highlighted by
Sutander-Pinnock, Woodside, Carter, Olmstead, & Kaplan (2003). In a longitudinal
study focusing on the relationship between perfectionism and treatment outcome among
anorexics, Sutander-Pinnock et a1. (2003) reported that the EDI-P was signiﬁcantly
associated with illness status. Individuals diagnosed with anorexia nervosa were assessed
for perfectionism upon admission to an inpatient eating disorders program, discharge, and
at a median of 15.9 months post-discharge. EDI-P scores were found to be sensitive to
illness status, whereas the Multidimensional Perfectionism Scale (MPS; Frost et al.,
1990) was less dependent on illness status. Although no other studies were found which
replicated this ﬁnding, it suggests that more comprehensive measures of perfectionism
can perhaps expand the current understanding of the relationships between different

dimensions of perfectionism and eating pathology.

40

Adaptive and Maladaptive Perfectionism within Eating Disorder Populations

In general, the limited literature examining the relationship between eating
pathology and multidimensional perfectionism has taken two different approaches. The
ﬁrst approach has involved distinguishing between adaptive and maladaptive, or normal
and neurotic perfectionism. The second approach has involved examining the unique
relationships between speciﬁc intrapersonal and interpersonal dimensions of
perfectionism and eating pathology. Within this literature base, some researchers have
argued that characterological differences exist among those diagnosed with anorexia
nervosa and those diagnosed with bulimia nervosa (Casper, 1983), while others have
argued that perfectionism is a key personality trait implicated in both disorders (Beebe,
1994; Heatherton & Baumeister, 1991; Slade, 1982).

Ashby, Kottman, & Schoen (1998) focused attention on perfectionism within a
clinical eating disorder population compared to a control group of undergraduate women.
Using the Multidimensional Perfectionism Scale (MPS; Frost et al., 1990) and the Almost
Perfect Scale (APS; Slaney, Ashby, & Trippi, 1995), no signiﬁcant differences were
found between the two groups on a factor representing adaptive perfectionism; however,
signiﬁcant differences were found on a factor representing maladaptive perfectionism.
Signiﬁcant relationships between maladaptive perfectionism and heightened levels of
body dissatisfaction, feelings of ineffectiveness, interpersonal distrust, and difﬁculty
responding to emotion, as measured by the Eating Disorders Inventory (EDI; Garner,
Olmstead, & Polevy, 1983b) led the authors to conclude that individuals with eating

disorders may be maladaptive perfectionists.

41

Mitzman, Slade, and Dewey (1994) speciﬁcally designed a measure, the Neurotic
Perfectionism Questionnaire (NPQ), to assess maladaptive aspects of perfectionism
assumed to be involved in eating disorder symptomatology. Neurotic perfectionism was
conceptualized as maintaining excessively high standards which are driven by a fear of
personal failure and a fear of disappointing others. Mitzman et al. (1994) found that the
NPQ successfully discriminated between individuals with eating disorders and those
without eating disorders, but the scale has been used infrequently by researchers.

In the largest study to date to examine perfectionism among eating disorder
subjects, the hypothesis that perfectionism represents a phenotypic trait in the
development of anorexia was tested in an international, multiple site study (Hamli et al.,
2000). A total of 322 anorexics diagnosed With restricting, purging, and binge eating
subtypes completed the Multidimensional Perfectionism Scale (MPS; Frost et al., 1990)
and the Perfectionism subscale from the Eating Disorders Inventory-2 (Garner, 1991).
Across anorexic subtypes, anorexics evidenced signiﬁcantly higher EDI-2 Perfectionism
subscale scores compared to normative data for the instrument. Additionally, across
subtypes, anorexics evidenced signiﬁcantly higher MPS perfectionism scores than a
healthy comparison group. An analysis of subscale scores on the MPS revealed
signiﬁcant differences between anorexics and healthy controls on all subscale scores
except perfectionistic strivings for organization, generally considered an adaptive aspect
of perfectionism. The purging without binge eating subtype subjects demonstrated
signiﬁcantly higher Parental Criticism subscale scores than the restrictive type.

Overall, greater perfectionism was associated with greater eating pathology and a

diminished motivation to change. Although this study did not speciﬁcally address

42

adaptive and maladaptive aspects of perfectionism, previous research involving factor
analysis found that the MPS subscales Concern Over Mistakes, Doubts about Actions,
Parental Expectations, and Parental Criticism loaded on to a maladaptive perfectionism
factor, while Personal Standards loaded on to an adaptive perfectionism factor (Frost et
al., 1990, Slaney et al., 1995). Based on these factor loadings, the Hamli et a1. (2000)
study suggests anorexics may differ from a non-eating disorder population on both
adaptive and maladaptive aspects of perfectionism.

Other researchers have examined the potential interaction of perfectionism and
other psychological variables associated with eating disorders, such as low self-esteem
and body dissatisfaction. Perfectionism has been assumed to negatively inﬂuence body
esteem, or body satisfaction, thus contributing to the development and maintenance of
eating pathology through its interaction with negative body image perceptions. Several
studies have found an inverse association between perfectionism and body image (Hewitt
et al., 1995; Terry-Short et al., 1995). A study by Davis (1997) supports this association,
suggesting that negative body esteem is most evident in neurotic/maladaptive
perfectionism. However, Davis (1997) relies on the Self-Oriented Perfectionism (SOP)
subscale of the Multidimensional Perfectionism Scale (MPS; Hewitt & Flett, 1991) to
measure normal/adaptive perfectionism and the Neurotic Perfectionism Questionnaire
(NPQ; Mitzman et al., 1994) to measure neurotic/maladaptive perfectionism. Goldner et
al. (2002) suggest that the SOP subscale was never intended to measure purely adaptive
aspects of perfectionism and the NPQ has been criticized for confounding perfectionism

with neuroticism, thus rendering Davis’ (1997) results questionable.

43

In conclusion, empirical evidence suggests maladaptive perfectionism may be a
prominent characteristic among individuals with eating disorders. The role of adaptive
perfectionism is less clear, suggesting continued research is needed. These ﬁndings
further suggest an alternative approach to conceptualization of perfectionism, which
focuses on the source and target of perfectionistic expectations rather than the presumed
adaptiveness or maladaptiveness of perfectionism, can supplement the current
understanding of the role of perfectionism in eating disorders.

Intrapersonal and Interpersonal Dimensions of Perfectionism in Eating Disorder
Populations

A second approach to specifying the relationship between perfectionism and
eating pathology involves examining speciﬁc relationships between intrapersonal and
interpersonal dimensions of perfectionism and eating pathology. Research has found
elevated levels of self-oriented perfectionism and socially prescribed perfectionism in
eating disorder populations; but, in general, has failed to ﬁnd signiﬁcant differences in
other-oriented perfectionism between eating disorder populations and nonaffected
populations. Self-oriented perfectionism and socially prescribed perfectionism have both
been implicated in disorders that involve self-concept, and self-concept is central to the
development of eating disorders. According to Hewitt and Flett (2002):

The important facets of self-oriented perfectionism include strong motivations for

the self to be perfect, maintaining unrealistic self-expectations in the face of

failure, stringent self-evaluations that focus on one’s own ﬂaws and shortcomings,
and generalization of unrealistic expectations and evaluations across behavioral

domains. (p. 256)

In contrast, “socially prescribed perfectionism entails the perception that others impose
unrealistic demands and perfectionistic motives for oneself and will be satisﬁed only
when those demands are met” (Hewitt & F lett, 2002, p. 256-257). Thus, for socially-
prescribed perfectionists, one’s self-concept is heavily inﬂuenced by the perceived
perceptions of others.

One signiﬁcant limitation concerning the research on self-oriented perfectionism,
socially prescribed perfectionism, and other-oriented perfectionism in eating disorders
involves a heavy reliance on nonclinical samples. A second signiﬁcant limitation
involves the lack of prospective studies. For example, in a cross-sectional study of 363
Canadian middle school girls, hierarchical multiple regression was used to examine risk
and protective factors associated with disordered eating during early adolescence
(McVey, Pepler, Davis, Flett, & Abdolell, 2002). In addition to high self-oriented
perfectionism, low competence ratings for appearance, low paternal social support, and
highly valued peer social acceptance were all signiﬁcantly associated with disordered
eating. Socially prescribed perfectionism, high value on physical appearance,
competence in social acceptance by peers, and maternal support were not signiﬁcantly
related to disordered eating. Yet, the mean age of participants (12.9 years), cross-
sectional design, limited geographic region, and use of a nonclinical sample limits the
generalizability of the results.

Pratt, Telch, Lobouvie, Wilson, & Agras (1999) investigated self-oriented
perfectionism, socially prescribed perfectionism, and other-oriented perfectionism in a
community sample of 127 adult women with binge eating disorder. No signiﬁcant

differences in perfectionism were found between the binge eating group and a

45

comparison group of 32 bulimic women of normal weight. While both the binge eating
group and the bulimic group evidenced signiﬁcantly higher self-oriented perfectionism
scores compared to a control group of 60 obese, non-eating-disordered women, self-
oriented perfectionism did not signiﬁcantly relate to any of the eating pathology
measures. As a result, Pratt et al. (1991) concluded that self-oriented perfectionism is not
speciﬁc to binge eating disorder symptoms, but is indicative of general psychiatric
symptomatology.

No differences were found between the three groups on other-oriented
perfectionism scores or socially prescribed perfectionism, but socially prescribed
perfectionism was signiﬁcantly associated with variables associated with binge eating
disorder, including general psychiatric symptom severity, weight concern, shape concern,
eating concerns, binge eating, and low self-esteem. Yet, again, the use of a non-
treatment-seeking community sample limits the generalizability of the results; replication
in a clinical population would strengthen the results as signiﬁcant differences may exist
between women who seek treatment as those who do not.

Hewitt et al. (1995) examined the relationship between self-oriented
perfectionism (SOP) socially prescribed perfectionism (SPP), other-oriented
perfectionism (OOP), and eating pathology in a nonclinical sample of 81 college women.
Results indicated that SOP related only to anorexic attitudes and behaviors, whereas SPP
was broadly associated with disordered eating patterns, self-esteem, and concerns about
appearance. As a side note, this ﬁnding may help explain the lack of signiﬁcant
relationship between self-oriented perfectionism and eating pathology in the Pratt et al.

(1991) study, because anorexics were not included among participants in the Pratt et al.

46

(1991) study. OOP demonstrated an unexpected signiﬁcant relationship with body image
avoidance, and the authors speculated that a need for others to be perfect may have
implications for revealing one’s own body (Hewitt et al., 1995). Hewitt et a1. (1995)
concluded that SOP may motivate eating disorder symptoms, such as a drive for thinness
and dieting behaviors, but social aspects of perfectionism play a central role in associated
features of eating disorders such as concerns about appearance and low self-esteem.
Stated differently, the strong need to conform to the perceived ideals of perfection of
others may set the foundation for eating pathology, but self-imposed standards of
perfection may speciﬁcally lead to eating disordered behaviors.

In review, research using multidimensional measures of perfectionism clearly
supports the continued investigation of the relationship between perfectionism and eating
disorders. A previously addressed, maladaptive perfectionism is proposed to represent a
prominent characterological trait of individuals with eating disorders. Elevated levels of
socially prescribed perfectionism reported within eating disorder populations supports
this proposition, as SPP is generally considered maladaptive in nature. However,
research has not substantiated a signiﬁcant relationship between other-oriented
perfection, also considered maladaptive in nature, and eating disorders. The differential
ﬁndings between SPP and OOP may be best understood in relation to self-concept (i.e.
the mental image one has of one’s self). SPP and eating disorders each appear to be
centrally related to self-concept and one’s own behavior, whereas GOP is predominantly
concerned with the mental image one has of others and others’ behavior.

Self-concept also plays a pivotal role in self-oriented perfectionism. Although

SOP is generally considered adaptive, and elevated levels of SOP have been reported in

47

eating disorder populations, the role of adaptive perfectionism in eating disorders is
unclear. The diathesis-stress model of perfectionism suggests a plausible explanation for
both the presence of elevated levels of SPP in eating disorder populations and the
uncertainty concerning the role of adaptive perfectionism. The diathesis-stress model of
perfectionism suggests that perfectionism can be adaptive in some situations, but can
become maladaptive under stressful situations. Speciﬁcally, previously adaptive aspects
of perfectionism are likely to become maladaptive when individuals are faced with ego-
involving situations that threaten one’s self-concept. In order to protect one’s self-
esteem, the evaluative component of one’s self-concept, certain individuals may adopt a
self-presentational style that promotes the appearance of perfectionism ( Goldner et al.,
2002).
Perfectionistic Self—Presentation within Eating Disorder Populations

Hewitt et al. (1995) also examined perfectionistic self-presentation, an aspect of
perfectionism previously unexplored in the eating disorders literature. A signiﬁcant
association was found between perfectionistic self-presentation (i.e. “needs to present to
others an image of perfection or avoid revealing imperfection in the self”) and anorexic
tendencies, bulimic tendencies, concerns about social reactions to one’s appearance, and
concerns about evaluations of one’s appearance. Perfectionistic self-presentation not
only showed unique variance in the prediction of body image avoidance and self-esteem,
but was revealed to be the best predictor of various dimensions of self-esteem among all
dimensions of perfectionism analyzed. The authors hypothesized that perfectionistic self-
presentation may represent an attempt to compensate for low self-esteem. Although this

study focused on a nonclinical population, similar results have been reported elsewhere.

48

For example, in a study of 100 female college students, Pliner and Haddock (1996)
reported that extremely weight concerned participants, in comparison to women who
were not excessively concerned about their weight, set unrealistically high standards for
others, set lower standards for themselves in the absence of external standards, and were
more strongly inﬂuenced by feedback. Pliner & Haddock (1996) supported the
hypothesized relationship between perfectionistic self-presentation and self-esteem,
suggesting that the excessively weight concerned women set lower goals for themselves
in order to maintain self-esteem.

Similar conclusions have been drawn from a clinical population. Compared to a
psychiatric control group and a normal control group, Geller, Cockell, Hewitt, Goldner,
and Flett (2000) found that a clinical anorexic group scored signiﬁcantly higher on a
measure of anger suppression and four interpersonal cognitive schemas assessed by the
Silencing of Self Scale (STSS; Jack & Dill, 1992). The four cognitive schemas assessed
included the tendency to present a compliant outer self while suppressing anger and
hostility, inhibition of self-expression to avoid interpersonal conﬂict, the tendency to
place others’ needs before one’s own needs, and the tendency to judge the self by
external standards. Controlling for global functioning, depression, and self-esteem, the
anorexic group continued to exhibit signiﬁcantly elevated scores compared to the control
groups on subscales measuring the tendency to give priority to others’ need and
inhibition of self-expression. Subscale scores for each of the four cognitive schemas and
anger suppression scores demonstrated signiﬁcant correlations with self-oriented
perfectionism, socially prescribed perfectionism, and perfectionistic self-presentation, but

did not signiﬁcantly relate to other-oriented perfectionism. A signiﬁcant relationship was

49

also found between inhibited expression of feelings, an interpersonal orientation, and
body satisfaction.

These results have been partially replicated in a study of 23S subclinical
adolescents (Zaitsoff, Geller, & Srikameswaren, 2002). Relative to adolescents with low
scores of eating disorder symptomatology, adolescents with higher eating
symptomatology scores exhibited signiﬁcantly higher anger suppression scores and
signiﬁcantly higher scores on 3 of the 4 interpersonal cognitive schemas assessed by the
STSS subscales (Zaitsoff et al., 2002). Unlike Geller et al. (2000), no signiﬁcant
differences were found regarding the Care subscale, which assesses the tendency to give
priority to others’ needs over one’s own needs. Although the speciﬁc risk factors of
weight-based and shape-based self-esteem and the general risk factor of global self-
esteem accounted for the greatest variance in eating disorder symptomatology scores, the
three silencing the self subscale scores and the anger suppression scores accounted for
additional, unique variance even after controlling for each type of self-esteem.

The clinical implications of perfectionistic self-presentation in eating disorder
clients is far-reaching. First and foremost, the need to appear perfect or avoid displays of
imperfection may prevent individuals from seeking treatment because seeking treatment
may be equated with failure. Second, if treatment is sought, a perfectionistic self-
presentation style is likely to interfere with the process of establishing a working alliance
due to fear of disclosure and the threat self-disclosure poses to one’s self-esteem. Unless
a client’s perfectionistic self-presentational style is recognized and addressed as part of
the treatment process, therapeutic progress may be compromised and, ultimately, the

chances for recovery lessened.

50

Eating Disorders and Deliberate Self-Harm

The comorbid relationship between eating disorders and DSH is rarely discussed
in the empirical literature, and the empirical basis for the relationship is limited. The
paucity of research is surprising given that many theorists view eating disorders and DSH
as different manifestations of the same underlying deﬁcits in self-care capacities and
emotional regulation (Conterio & Lader, 1998; Favazza, 1996; Miller, 1994), and eating
disorders are one of the diagnoses most frequently associated with DSH (Dulit et al.,
1994; Favazza, DeRosear, & Conterio, 1989; Herpertz, 1995). As a whole, the few
studies addressing the comorbidity of eating disorders and DSH are characterized by
small sample sizes, limited power, discrepant deﬁnitions of eating disorders and DSH,
and failure to assess for the presence of personality disorders (Paul, Schroeter, Dahme, &
Tiulzinger, 2000). Within these studies, comorbidity estimates have varied widely based
on method of assessment and based on the primary presenting problem under study.

Theoretically, the link between eating disorders and DSH has been explained in
terms of shared psychological correlates and common risk factors. Diagnostically, the
link between eating disorders and DSH has been explained in terms of a “Repetitive Self-
Harm Syndrome,” a multi-impulsive personality disorder, multi-impulsive bulimia, and
borderline personality disorder. Each of these diagnoses has been presented as a means
to understand the comorbid development of eating disorders and DSH. The following
section ﬁrst addresses possible explanations for the range of comorbidity estimates, and
then reviews existing theoretical and diagnostic explanations for the overlap between

eating disorders and DSH.

51

Eating Disorder and DSH Comorbidity Estimates

As pointed out by Sansone & Sansone (2002), one issue impeding empirical
progress in this area involves the lack of assessment instruments addressing potential
comorbidity. In a review of current measures used to assess eating disorder
symptomatology, Sansone & Sansone (2002) noted that none of the measures contained
items assessing for the presence of DSH. Several of the DSH measures reviewed
contained items assessing eating disorder symptomatology, but the number of items was
insufﬁcient to make an eating disorder diagnosis (Sansone & Sansone, 2002). More
importantly, standardized measures of DSH do not exist, and the only DSH measure to
report reliability and validity estimates (i.e. the Deliberate Self-Harm Inventory; DSHI;
Gratz, 2001) has not been validated in a clinical population. The lack of appropriate
instrumentation and failure to assess for the presence of personality disorders may
provide a partial explanation for the wide variation in reported estimates of comorbidity.

Eating disorder and DSH comorbidity estimates have varied greatly based on the
primary presenting problem of participants in each study, as well as the speciﬁc eating
disorder subtype studied. For instance, Paul et al. (2002) estimated that approximately
61% of the DSH population suffers from a comorbid eating disorder, whereas Farber
(2000) reported that between 57% and 93.3% of the DSH population exhibits a comorbid
eating disorder. Favazza et al. (1989) found that among a mixed sample of 290 self-
harrners from an inpatient program and from the community, 50% of participants
indicated a current or past history of an eating disorder. Anorexia was endorsed by 15%
of participants; bulimia was endorsed by 22% of participants; and 13% of participants

endorsed both anorexia and bulimia (F avazza et al., 1989).

52

Comorbidity estimates have also varied within the eating disorders literature.
Farber (2000) estimated that between 8.9% and 26.6% of bulimics engage in DSH, and
Garﬁnkel, Moldofski, & Garner (1980) reported DSH among 9.2% of the 68 bulimics
they studied. Favazza (as cited in Conterio & Lader, 1998) estimated that 40.5% of
bulimics and 35% of anorexics engage in DSH, based on a review of several studies.
Sansone et al. (2003) estimated that approximately 25% of the eating disorder population
engages in DSH, regardless of speciﬁc eating disorder diagnosis or diagnostic subtype,
but other researchers contend that DSH is more common in a bulimic population. The
hypothesis that DSH is more common in a bulimic population has received some
empirical support. Both bulimia (Fichter, Quadﬂieg, & Rief, 1994; Weiderman & Pryor,
1996) and DSH (Favazza & Rosenthal, 1993) have been linked to deﬁcits in impulse
control. Anorexia, in contrast, has shown a stronger relationship to obsessive compulsive
behaviors (Holden, 1990; Thorton & Russel, 1997). Yet, at least one study found a
similarly high incidence of DSH in an anorexic population compared to a bulimic
population (Baral, Kora, Yuksel, & Sezgin, 1998). Furthermore, even though impulsivity
and compulsivity are considered separate psychological traits, impulsive and compulsive
behaviors often coexist (McElroy, Pope, Keek, & Hudson, 1995; Rasmussen & Eisen,
1994). Individuals with eating disorders often display coexistent impulsive and
compulsive symptoms (Favaro & Santonastaso, 1998; Newton, Freeman, & Munro,
1993).
Theoretical Explanations for Eating Disorder and DSH Comorbidity

Theoretically, the relationship between eating disorders and DSH is complex.

While the idiosyncratic meanings behind eating disorders and DSH vary between

53

individuals, eating disorders and DSH appear to share similar, multiple psychological
functions, and are remarkably similar in terms of age of onset, sex ratio, and
psychological correlates. According to Alderman:

Each type of activity may be used as a way of coping with great internal pain.

Both can provide a way to relieve or release tension, of communicating with

others [one’s] own internal state, to regulate dissociate states, and to physically

express [one’s] psychological state. (p. 97-98)

Heatherton & Baumeister (1991) hypothesized that binge eating may be a form of
dissociation or a means to induce dissociation, paralleling the hypothesized relationship
between DSH and dissociation (F avazza & Simeon, 1995; van der Kolk et al., 1991).
DSH and eating disorders have each been associated with high levels of self-reported
dissociative symptoms (Abraham & Beaumont, 1992; Everill, Waller, & MacDonald,
1995). Additionally, women with comorbid DSH and bulimia have been found to exhibit
higher scores on a measure of self-transcendence compared to groups of suicidal bulimic
women and bulimic women with no histories of DSH or suicidal behavior, thus
suggesting a greater sense of disconnectedness and dissociation among this population
(Anderson, Carter, McIntosh, Joyce, & Bulik, 2002). According to Favaro (1998), DSH
in eating disorders represents a means of tension release which is often used as an
alternative to binging; both DSH and binging serve as a means of experiencing one’s one
body and re-establishing a sense of reality.

A history of child abuse and trauma constitutes another shared risk factor in the
development of DSH and eating disorders. Some evidence suggests that child abuse and

trauma has the potential to explain the high co-occurrence of DSH and eating disorders

54

(Deep, Lilenfeld, Plotniciv, Pollice, & Kaye, 1999; F avaro & Santonastoso, 1998;
Wonderlich et al., 2000; Wonderlich et al., 2001). Yet, similar to the DSH literature,
discrepant results have been found in regards to whether childhood abuse and trauma
represents a general or speciﬁc risk factor in the development of eating disorders (Everill
& Waller, 1995; Lacey & Evans, 1986; Welch & Fairburn, 1994). Although dissociation
and a history of child abuse and trauma are the shared risk factors most often cited to
explain the co-development of eating disorders and DSH, additional shared risk factors
have also been identiﬁed. These factors include poor self-esteem, depression, substance
abuse, poor problem-solving skills, negative body image, body alienation, compulsivity,
and impulsivity.
Diagnostic Explanations for Eating Disorder and DSH Comorbidity

Repetitive Self-Harm Syndrome. Favazza & Rosenthal (1993) proposed that the
comorbidity between DSH, eating disorders, and other impulsive behaviors could be
understood in terms of a “Repetitive Self-Harm Syndrome,” in which DSH is
“interphased with periods of quiescence, eating disorders, episodic alcohol and substance
abuse, or kleptomania” (p. 136). The syndrome has no set course; characteristic
behaviors may occur simultaneously or, alternatively, some behaviors may diminish as
other symptoms become more predominant. Recognizing that DSH can occur
sporadically in the context of other Axis I and Axis II mental disorders, Favazza &
Rosenthal (1993) recommended diagnosing Repetitive Self-Harm Syndrome when DSH
assumes an autonomous course and the behaviors are incorporated into one’s self-
identity. Primarily considered a disorder of impulse control, Favazza & Rosenthal (1993)

also highlighted possible compulsive features: “People with the disorder may brood

55

about banning themselves for hours or days and may engage in ritualistic behaviors such
as tracing areas of their skin and placing their self-harm paraphernalia in a special order”
(p. 137).

Multi-impulsive personality disorder. Other theorists have proposed models
conceptually similar to the Repetitive Self-Harm Syndrome. From an eating disorders
perspective, the comorbidity between eating disorders and DSH has been conceptualized
in terms of a multi-impulsive personality disorder (Lacey & Evans, 1986), and more
speciﬁcally, in terms of multi-impulsive bulimia (Lacey, 1993). Both the Repetitive Self-
Harm Syndrome and multi-impulsive bulimia appear to be conceptually driven by Lacey
and Evans’ (1986) conceptualization of multi-impulsive personality disorder. After
reviewing the literature on impulsivity, impulse control disorders, and disorders
perceived to be related to impulse control, Lacey and Evans (1986) proposed that within
each population of “uni-impulsive disorders,” a subset of individuals display multiple
impulse control problems that are characterologically-based. Individuals displaying
multiple patterns of impulsivity were argued to form a unitary subgroup with a “multi-
impulsive personality disorder” (Lacey & Evans, 1986). Furthermore, it was argued that
this subgroup has a poor prognosis because clinicians typically address the presenting
impulsive behavior and fail to address underlying characterological problems with
impulse control. As a result, symptom substitution occurs and individuals with multi-
impulsive personality disorder alternate predominant impulsive behaviors. For example,
Lacey and Evans (1986) posited that “if alcohol abuse is addressed in the alcohol
treatment unit, the patient may stop drinking but move to food or cutting” (p. 646). The

same reasoning applies to the comorbidity between DSH and eating disorders: If only

56

one problem area is addressed in treatment, symptoms are likely to increase in the non-
addressed problem area.

Multi-impulsive bulimia. In addition to suggesting a multi-impulsive personality
disorder, Lacey (1993) formulated diagnostic criteria for a multi-impulsive form of
bulimia. The term “multi-impulsive bulimia” was introduced to describe a subset of
bulimics who exhibit impulse control problems associated with bulimia in one of the
following areas: gross alcohol abuse, “street drug” abuse, multiple drug overdoses,
repeated self-harm, sexual disinhibition, or shoplifting. In multi-impulsive bulimia, each
of these behaviors is interchangeable and impulsive, each is associated with a similar
sense of being out of control, and suppression of these behaviors results in intense anger
and depression. Lacey (1993) noted that multi-impulsive bulimia is strongly associated
with DSH and a poor prognosis.

Studies examining multi-impulsive bulimia have reported rates ranging between
18% and 80% in a bulimic population (Fahy & Eisler, 1993; Wiederman & Pryor, 1996).
However, these studies differ not only in terms of sample characteristics, but also in
diagnostic criteria used to evaluate the presence of multi-impulsive bulimia. As
highlighted by Bell & Newns (2002), the number of impulsive behaviors which constitute
multi-impulsivity range from two to eight, the types of impulsive behaviors under
investigation vary between studies, and the time period in which impulsive behaviors are
assessed ranges ﬁ'om the previous month to lifetime occurrence.

In support of the validity of a multi-impulsive bulimia diagnosis, some evidence
exists that multi-impulsive bulimics exhibit greater general psychopathology and lower

adaptive functioning than other non-impulsive bulimics (Fichter et al., 1994; Weiderman

57

& Pryor, 1996). However, the concept of multi-impulsive bulimia has not been
uniformly accepted. Welch & Fairbum (1996) posited that different impulsive behaviors,
including DSH and substance abuse, may each have different relationships with bulimia,
and explaining eating disorder comorbidity in terms of multi-impulsive bulimia may be
premature. Similarly, F ahy & Eisler (1993) found that multi-impulsive bulimics
exhibited more severe bulimic symptoms than non-impulsive bulimics, but argued that a
separate diagnostic category was not warranted. Fahy & Eisler (1993) hypothesized that
the majority of impulsive behaviors do not result from impulsivity, or the failure to
consider risks and consequences before acting, but instead result from affective
disturbances. Lacey & Evans (1986) conceded that multi-impulsive personality disorder
could be a variant of borderline personality disorder, thereby suggesting that multi-
impulsive bulimia and its associated impulsive behaviors may also be understood in
relationship to borderline personality disorder.

Borderline personality disorder. In an on-going study in which data has been
collected from 46 bulimics to date, 33% of participants met the criteria for borderline
personality disorder (Wonderlich, Myers, Norton, & Crosby, 2002). Of those meeting
borderline personality disorder criteria, 47% of participants endorsed one or more
lifetime occurrences of DSH. Comparatively, 61% of participants meeting the criteria for
multi-impulsive bulimia endorsed one or more lifetime occurrences of DSH. Less than
9% of participants who did not meet criteria for either borderline personality disorder or
multi-impulsive bulimia endorsed a lifetime history of DSH. As a result, the authors
concluded that a lifetime history of DSH among a bulimic population was highly

suggestive of the presence of either multi-impulsive bulimia or an underlying borderline

58

personality structure. However, this conclusion may be premature given the nature in
which DSH was assessed; DSH was assessed in terms of participants’ responses to one
question regarding lifetime occurrence of DSH.

According to Wonderlich & Mitchell (1997), approximately 20% of individuals
with bulimia carry a comorbid borderline personality disorder diagnosis. Individuals
with comorbid bulimia and borderline personality disorder diagnoses display greater
mood disturbances, family distress, general dysfunction, and a higher number of self-
destructive behaviors (Wonderlich & Mitchell, 1997). Yet, again, DSH assessment was
limited to one question concerning lifetime occurrence of DSH.

It is important to note that the relationship between eating disorders and DSH can
not be fully explained by the presence of a borderline personality disorder. Using
borderline personality disorder and suicidal behavior as an exclusion criteria, Favaro &
Santonastoso (1998) found a 34.6% lifetime prevalence rate of DSH among an inpatient
German eating disorder population. The sample included a total of 376 women: 119
anorexic individuals (restricting subtype, n= 59; purging subtype, n= 59), 137 bulimic
individuals, and 120 individuals diagnosed with an eating disorder not otherwise
speciﬁed. The highest rates of DSH were found among women diagnosed with eating
disorders not otherwise speciﬁed (35.8%) and bulimia (34.7%). No signiﬁcant
differences in DSH emerged between anorexic subtypes. Within the total sample, 49.2%
reported DSH onset post-eating disorder, 25.5% reported DSH onset pre-eating disorder,
and the remaining participants reported simultaneous onset of DSH and eating disorder.
The DSH group reported a higher number of traumatic events, higher scores on two of

the three dissociation subscales used, and more obsessive thoughts and behaviors. No

59

differences were found between individuals reporting DSH and those who did not on
measures of behavioral impulsivity, but the DSH group exhibited higher cognitive
impulsivity scores.

In summary, despite the methodological limitations of the empirical literature,
evidence supports high co-occurrence of DSH and eating disorders. Among eating
disorder subtypes, a speciﬁc link has been found between DSH and bulimia, while the
relationship between other eating disorder subtypes and DSH is less clear. Multiple
psychological factors have been explored in an attempt to further understand the
underlying mechanisms responsible for DSH and eating disorder comorbidity. These
factors include impulsivity, compulsivity, body dissatisfaction, dissociation, and history
of child abuse and trauma. Diagnoses of Repetitive Self-Harm Syndrome, multi-
impulsive personality disorder, multi-impulsive bulimia, and borderline personality
disorder have each been suggested as a means to organize and understand the
interrelationships between several of these psychological factors. Yet, continued inquiry
is needed as both DSH and eating disorders are believed to be multidetermined disorders
of heterogeneous origin. For example, perfectionism represents an unexplored premorbid
personality trait that may serve as a vulnerability factor contributing to the comorbidity of
DSH and eating disorders, but before this line of inquiry is pursued, it is ﬁrst necessary to
establish an empirical relationship between perfectionism and DSH.

Perfectionism and DSH

Given the lack of empirical research linking perfectionism and DSH, the purpose

of the following section is to 1) suggest a theoretical link between perfectionism and

DSH; and 2) provide anecdotal evidence in support of the hypothesized relationship

60

between perfectionism and DSH. Attachment theory is suggested as a viable framework
from which to conceptualize the proposed relationship between perfectionism and DSH,
and the anecdotal evidence is presented in the context of developmental models of
perfectionism.

Conceptual models of perfectionism and conceptual models of DSH each heavily
emphasize the role of early parent-child relationships and the familial environment, but
empirical evidence in support of the etiological role of attachment relationships is
minimal in both bodies of literature. As previously discussed, the empirical literature on
the etiology of DSH, while limited, suggests that the perceived quality of early parent-
child attachment relationships is an important etiological factor in the development of
DSH. Within the perfectionism literature, a strong association has been reported between
perfectionism and attachment variables such as relationship preoccupation and need for
approval (Andersson & Ferris, 2000). Additionally, small, signiﬁcant correlations have
been found between perfectionism and lack of secure attachment, avoidant attachment,
relationship ambivalence, and fear of abandonment (Brennan & Shaver, 1995).
However, empirical evidence linking attachment security and perfectionism remains
tentative and largely conceptual.

In a review of the perfectionism literature, Flett, Hewitt, Oliver, and Macdonald
(2002) outlined four conceptual models to explain the development of perfectionism: the
social expectations model, the social reaction model, the anxious rearing model, and the
social learning model. These four models of perfectionism do not distinguish between
family environmental conditions that promote adaptive aspects of perfectionism and

those that promote maladaptive aspects of perfectionism. However, a common theme

61

among the models is the importance of parent-child interactions in the development of
perfectionism; thus suggesting the quality of attachment relationships may set the stage
for later development of perfectionism.

The social expectations model suggests that perfectionism develops in response to
parental approval which is contingent on meeting high standards of performance, which
in turn leads to contingent self-worth. Children learn that perfection results in parental
approval; thus perfectionism becomes a means to maintain attachment security and self-
worth. Failure to consistently meet parental standards can lead to an inability to maintain
self-worth and can foster a chronic sense of helplessness. According to Flett et a1.
(2002), “In general, exposure to conditions that foster a sense of conditional self-worth
also increase that likelihood that a state of helplessness will develop (p. 90). Feelings of
helplessness have been identiﬁed as one of the most common precipitants of DSH
(Alderman, 1997; Conterio & Lader, 1998). The following excerpt illustrates the
potential role of perfectionism and contingent self-worth in DSH (Strong, 1998):

Barbara graduated at the top of her high school class and earned a bachelor’s

degree from Brigham Young University. During her college years she didn’t self-

injure often. When she did it was usually brought on by demands she felt she
could not meet—like being able to maintain the straight-A average she kept in

high school. (p. 15)

When failure to meet perfectionistic expectations results in feelings of diminished self-
worth and helplessness, DSH may be adopted as a means to punish and degrade the

unworthy self (Deiter, Nicholls, & Pearlman, 2000).

62

Hamachek (197 8) indicates that perfectionism may also develop in the absence of
parental expectations. Without clear parental expectations and standards, a child may
adopt perfectionism as a defensive strategy to avoid punishment. As noted by Flett et al.
(2002), adults in treatment have reported adopting perfectionism in response to parental
neglect. In turn, parental neglect has been found to negatively impact two of the
presumed primary functions of DSH: emotional regulation and affective expression.
According to Dieter et al. (2000), “Expressing or externalizing affective states is the
primary function of self-injury” (p. 1181).

The social reaction model of perfectionism suggests that perfectionism develops
in response to being raised in a harsh environment characterized by hostility or lack of
warmth. Exposure to abuse, neglect, withdrawal of love, or shaming situations may
individually or interactively foster the development of perfectionism; as previously
discussed, these same environmental conditions have been implicated in the development
of DSH. According to the social reaction model, perfectionism develops as a means to
establish predictability in an unpredictable environment, reduce exposure to shame and
humiliation, and minimize abuse (Flett et al., 2002). The following excerpt provides an
example of a perfectionistic self-harmer with a history of sexual abuse (Strong, 1998):

[Erin] can’t bear conﬂict or criticism. She tries to please everybody, save

everybody, ease everyone’s pain. But she hates herself in the process because she

isn’t revealing her true feelings. . ..As Erin grew up, she played out two very
different roles: good girl and bad girl. She became a slave to perfectionism. She
graduated with a perfect 4.0 grade-point average even though she missed an entire

year of high school while she was in the psychiatric ward. (p. 206-207)

63

In the context of a harsh environment, perfectionism and DSH may each independently
develop as a means of establishing control in an uncontrollable environment. As
explained by one woman, “Self-harm gives me a feeling of control when I cannot ﬁnd
control in the environment” (as cited in F avazza, 1989, p. 139).

The anxious rearing model suggests that perfectionism develops in response to
anxious parents who focus on mistakes and the negative consequences of making
mistakes; as a result, perfection develops as a strategy to avoid exposure of mistakes.
Under these circumstances, perfectionism can be viewed as a characterological
vulnerability which discourages the adaptive communication of psychological stress
through pressures to be perfect and pressures to present oneself as perfect. DSH, in turn,
can be viewed as a compensatory mechanism used by individuals who are unable to
adaptively communicate their psychological distress regulate affect.

Together, the ﬁrst three models suggest perfectionism may develop as a defense
mechanism adopted to avoid harsh criticism and punishment within insecure parent-child
attachment relationships. Alternatively, the social learning model suggests that
perfectionism develops through modeling and idealization of attachment ﬁgures, thus the
development of perfectionism can be explained in terms of children imitating
perfectionistic parents. According to F lett et al. (2000):

Perfectionism is likely to develop not only when children are exposed to

authoritarian parenting and an emotional climate that emphasizes the negative

consequences of making mistakes but also when parents engage in speciﬁc
behaviors designed to promote perfectionism (e.g., placing children in demanding

situations that emphasize the attainment of standards and meeting expectations)

and when parents express perfectionistic goals and standards. (p. 109)

Yet, as emphasized by Flett et al. (2002), parental behaviors alone are an inadequate
explanation for the development of perfectionism. Broader environmental factors and
individual child characteristics must also be considered. For instance, the development of
perfectionism depends, in part, on whether the child intemalizes pressures to be perfect,
extemalizes pressures to be perfect, or actively rejects pressures to be perfect and rebels.
Stated differently, the quality of parent-child attachment relationships appears to provide
a foundation for the development of perfectionism, but numerous mediating and
moderating variables must be considered as well.

In summary, theorists have identiﬁed multiple developmental pathways to
perfectionism. The common theme of the models involves the importance of the quality
of parent-child interactions. Similarly, the quality of parent-child interactions has been
identiﬁed as an etiological factor in the development of DSH. Additional empirical
research is needed in order to clarify the relative contribution of attachment relationships
in comparison to other risk factors in the development of perfectionism and DSH. If the
results of the current study support the hypothesized relationship between perfectionism
and DSH, attachment theory may serve as a theoretical foundation for future studies that
advance our understanding of the comorbidity between perfectionism and DSH.
Evidence of the relationship between perfectionism and DSH is currently limited to
anecdotal accounts. The primary goal of this study, therefore, is to examine empirically

the possible relationship between perfectionism and DSH.

65

CHAPTER 3

Methodology

A ﬁeld correlational design was utilized due to the population and variables under
study. This design was most appropriate because it would have been unethical to
manipulate the variables under study and impossible to randomly assign participants to
groups. The primary interest of this study was to examine the interrelationships between
DSH, eating disorders, and perfectionism; cause-effect statements were not of interest.
Participants

Participants included 85 women ranging in age from 18 to 48 years (M = 27.5,
SD = 7.9). All participants were seeking psychological help for issues related to DSH
and/or eating disorders at the time of study participation. Of the total sample, 84.7% of
participants were receiving outpatient treatment; 7.1% were receiving treatment in a
partial hospitalization program; 4.7% were receiving inpatient treatment; and 3.5% were
receiving treatment through participation in a support group alone. Several participants
were involved in multiple treatment modalities; 12.9% of participants were involved in a
support group in addition to outpatient treatment and 1 participant was involved in a
support group in addition to treatment in a partial hospitalization program.
Approximately half (51.8%) of the participants had received treatment for more than 1
year, while 16.5% of participants had been in treatment 1-6 months and 31.8% of
participants had received less than 6 months of treatment.

The total sample included 72 Caucasian women, 4 Hispanic/Latino women, 2

Asian/Asian—American women, 1 African-American woman, 3 multiracial women, and 3

66

women identifying their racial background as “other.” Whereas 19 participants were
married, 61 participants were single. The remaining participants were separated,
divorced, or widowed. Overall, participants exhibited a high degree of education, with
50.6% of the sample noting at least some college, 21.2% noting a college degree, 10.6%
noting some graduate work, and 12.9% noting a graduate degree. Yet, 67.1% of
participants reported earning less than $15,000 per year. The majority of participants
(75.3%) resided in the Midwest, while 21.2% of participants resided in California and
3.5% of participants resided in other parts of the country.
Instruments

Demographic questionnaire. The demographic questionnaire collected data
regarding the following variables: gender, age, race/ethnicity, marital status, number of
children, current living arrangements, state of residence, socioeconomic status, level of
education, employment status, and occupation. Data collected from the demographic
questionnaire were used to adequately describe the characteristics of the sample.

Help-Seeking and Treatment History Questionnaire. The Help-Seeking and
Treatment History Questionnaire, designed speciﬁcally for this study, collected
information regarding the following variables: receival of psychological treatment, type
of treatment received, length of psychological treatment, primary reasons for seeking
treatment, perceived effectiveness of treatment, presence or history of an eating disorder
diagnosis, presence or history of DSH behaviors, type and frequency of DSH behaviors
(if applicable), history of abuse/trauma, and therapeutic disclosure of DSH, eating
disorders, or abuse/trauma experiences when relevant to the participant. Data from the

Help-Seeking and Treatment History Questionnaire were used to determine group status

67

for analyses and to adequately describe the demographic characteristics and treatment
experiences of participants in each analysis group.

Multidimensional Perfectionism Scale—Frost (MPS; Frost et al., 1990). The Frost
et al. (1990) MPS is a 35-item instrument containing six subscales designed to measure
the nature and potential origins of trait perfectionism. Each item is responded to on a
Likert scale ranging from 1 (disagree strongly) to 5 (agree strongly), with higher scores
indicating greater perfectionism. The Organization subscale (6 items) assesses the
emphasis the respondent places on order and organization (i.e. “I try and be a neat
person”). A “total perfectionism” score is obtained from summing across items on the
remaining ﬁve subscales. The Concern Over Mistakes subscale (9 items) assesses the
tendency to respond negatively to perceived mistakes and equate mistakes with failure
(i.e. "People will probably think less of me if I make a mistake”). The Personal
Standards subscale (7 items) assesses high expectations for personal performance,
including high goals and standards (i.e. “1 hate being less than best at things”). Doubts
about Actions (4 items) assesses the tendency to doubt one’s ability to effectively
complete tasks (i.e. “I usually have doubts about the simple everyday things I do.”).
Parental Expectations (5 items) measures the respondent’s belief that his/her parents set
high standards and held high expectations for the respondent (i.e. “My parents expected
excellence from me.”). Parental Criticism (4 items) measures the respondent’s belief that
his/her parents were overly critical and failure to meet high standards would result in the
loss of acceptance (i.e. “As a child, I was punished for doing things less than perfectly.”).
Cronbach coefﬁcient alpha, ranging from .77 to .93, indicate adequate reliability for the

measure (Frost et al., 1990). The Frost et al. (1990) MPS has been widely used across

68

diagnostic groups to study a range of psychopathological symptoms, including abnormal
eating and eating disorders (Enns & Cox, 2002). Construct, concurrent, and discriminant
validity has been demonstrated across multiple studies (Enns & Cox, 2002).

Multidimensional Perfectionism Scale (MPS; Hewitt & F lett, 1991). Although
Hewitt & Flett’s (1991) MPS bears the same name of the Frost et al. (1990) measure, the
Hewitt & Flett (1991) MPS assesses distinctly different dimensions of trait perfectionism.
The Hewitt & Flett (1991) MPS consists of 45 items rated for agreement on a Likert scale
ranging from 1 (strongly disagree) to 7 (strongly agree). Items are evenly divided among
three subscales which reﬂect the source and target of perfectionistic expectations, with
higher scores on each subscale indicating greater perfectionism. Intercorrelations among
items indicate some degree of overlap, ranging from .25 to .40 (Hewitt & Flett, 1991).
The Self-Oriented Perfectionism (SOP) subscale assesses self-directed perfectionism
characterized by the setting of excessively high personal standards (i.e. “One of my goals
is to be perfect in everything I do.”). The Socially Prescribed Perfectionism (SPP)
subscale assesses the perception that others hold excessively high standards for one’s self
(i.e. “My family expects me to be perfect.”). The Other-Oriented Perfectionism (OOP)
subscale assesses one’s tendency to hold others to excessively high standards of behavior
and performance (i.e. “The people who matter most to me should never let me down”).
Internal consistency (a) was reported as .86 for the SOP subscale, .87 for the SPP
subscale, and .82 for the COP subscale in a college student sample (Hewitt & F lett,
1991); coefﬁcient alphas for the subscale in a psychiatric population were .88, .81, and
.74, respectively. Three month test-retest reliability (r) reports have ranged from .75

(SPP) to .88 (SOP) in a college student sample (Hewitt & Flett, 1991), and from .60

69

(SPP) to .69 (SOP) in a sample of psychiatric patients. Convergent, concurrent, and
discriminant validity has been established across multiple studies using a range of clinical
and nonclinical population including eating disorder populations. Additional data
indicates MPS subscales are relatively free from response bias (Hewitt & Flett, 1989;
1991a; 1991b).

Perfectionistic Self-Presentation Scale (PSPS; Hewitt et al., 2003). The PSPS
(Hewitt et al., 2003) is a 27-item instrument consisting of three subscales designed to
measure an individual’s need to appear perfect to others through action or avoidance.
Items are responded to on a Likert scale ranging from 1 (strongly disagree) to 7 (strongly
agree), with higher scores indicating greater self-presentational perfectionism. The
Perfectionistic Self-Promotion subscale (10 items) assesses one’s need to actively display
an ideal self that appears ﬂawless in public situations (i.e. “I strive to look perfect to
others”). The Nondisplay of Imperfection subscale (10 items) assesses concerns that
one’s actions in public will reveal perceived shortcomings and imperfections (i.e. “Errors
are much worse if they are made in public rather than in private”) The Nondisclosure of
Imperfection subscale (7 items) assesses avoidance of verbal disclosures of perceived
shortcomings or imperfections (i.e. “I should solve my own problems rather than admit
them to others”). Preliminary data indicate adequate reliability and validity (Hewitt et
al., 2003). Cronbach coefﬁcient alphas ((1) suggest good internal consistency of the
subscales. Three week test-retest coefficients for the Perfectionistic Self-Promotion,
Nondisplay of Imperfection, and Nondisclosure of Imperfection subscales were .83, .84,
and .74, respectively, in a college student sample; and .81, .81, and .79, respectively, in a

clinical population (Hewitt et al., 2003). Convergent validity was established through

70

signiﬁcant correlations between each of the PSPS subscales, and both signiﬁcant others’
and clinicians’ ratings of perfectionistic self-promotion, nondisplay of imperfection, and
nondisclosure of imperfection. Construct and predictive validity were also adequately
established (Hewitt et al., 2003).
Procedure

Participants were recruited from three different treatment settings: hospital-based
treatment programs, college counseling centers, and private practice outpatient settings.
All participants were recruited with the assistance of cooperating therapists employed in
these settings and identiﬁed as working with the populations under study. All
cooperating therapists were asked to assist in selecting appropriate participants to
minimize risks associated with participation. Anticipated risks involved with
participation included the possible activation of affect-laden memories and negative self-
evaluation. Due to the possibility of activating affect-laden memories and the possibility
of inducing negative self-evaluation, all cooperating therapists were informed of the
purpose of the study and asked to provide potential participants with times that they were
available to discuss potential feelings and reactions to study participation, if participants
felt the need to discuss their experience of participation. Potential beneﬁts associated
with study participation included increased self-awareness and self-understanding. Study
approval was obtained from all relevant institutional review boards.

Participants receiving hospital-based treatment were recruited from the S.A.F.E.
(Self Abuse Finally Ends) Alternative Program and from the Eating Disorders Program at
Linden Oaks at Edward Hospital, located in Naperville, Illinois. The S.A.F.E.

Alternative Program offers therapeutic services focusing speciﬁcally on DSH. Individual

71

therapy, group therapy, and outpatient therapy are provided in the context of partial/day
hospitalization and inpatient hospitalization programs. Recruitment efforts targeted both
programs to obtain a wider representation of individuals who seek treatment for DSH.
The Eating Disorders Program at Linden Oaks at Edward Hospital offers inpatient, partial
hospitalization, and intensive outpatient programs for individuals with eating disorders.
Recruitment efforts targeted multiple programs to obtain a wider representation of
individuals who seek treatment for eating disorders.

Participants receiving treatment in college counseling centers were drawn from
one mid-sized public university in Illinois and one large public university in Michigan.
Participants receiving treatment from private practice therapists were drawn from Illinois
and California. Potential cooperating therapists in private practice in California were
identiﬁed with the assistance of Dr. Tracy Alderman, Ph.D., a licensed clinical
psychologist based in the San Diego area. Dr. Alderman consults, lectures, and has
published on the treatment of DSH, thus placing her in regular contact with therapists
who treat adult women presenting with psychological issues related to DSH and eating
disorders. Additional potential cooperating therapists in California were identiﬁed based
on afﬁliation with the Association of Professionals Treating Eating Disorders in the San
Francisco Bay area. Potential cooperating therapists in private practice in Illinois were
identiﬁed from a list of therapists specializing in the treatment of eating disorders in
Illinois; this list was obtained from the National Association of Anorexia Nervosa and
Associated Disorders (ANAD).

Recruitment of all potential participants occurred as follows. Cooperating

therapists each received a Request for Therapist Assistance form (see Appendix A),

72

outlining the purpose of the study, the need for volunteer participants, and instructions for
distributing survey packets to clients. Survey packets included the following material: a
Participant Recruitment form (see Appendix B); two copies of an Informed Consent form
(see Appendix C for the general Informed Consent; see Appendix D for the Informed
Consent speciﬁc to Linden Oaks at Edward Hospital); a demographic questionnaire (see
Appendix E); a Help-Seeking and Treatment History Questionnaire (see Appendix F);
and a perfectionism questionnaire, containing the three perfectionism measures described
in detail at a later point in this chapter. Therapists were asked to distribute survey
packets to clients meeting study criterion, and inform clients of therapist availability to
discuss any feelings that arose as a result of participation, if clients chose to participate
and chose to share their decision to participate with their therapist. All cooperating
therapists received study materials from their program directors at their place of
employment, with the exception of private practice therapists. Cooperating private
practice therapists received study materials either from Dr. Alderman or through direct
contact with the researcher.

Potential participants were informed via the Participant Recruitment form that the
purpose of the study was to examine perfectionistic tendencies among females seeking
treatment for eating disorders and/or DSH in order to develop more effective treatments.
Potential participants were also instructed to read the Informed Consent form to obtain
additional study information. The Informed Consent form described precautions that
were taken to protect participant conﬁdentiality, described the potential beneﬁts and risks
associated with participation, and informed participants that the amount and type of

information they wished to share with their therapist regarding participation was their

73

decision. However, participants were encouraged to address any potential adverse effects
or feelings associated with participation with their therapist.

A place was provided on the Informed Consent form where participants could
indicate whether or not they wanted a copy of the completed study and the study’s
results. If participants requested a copy of the completed study, they were asked to
provide an e-mail address, home mailing address, or alternatively, were given the
researcher’s e-mail address so that they could request a copy of the results at a later date.
Each participant was given a copy of the Informed Consent for her own, and asked to
send a second, signed consent form to the researcher in a stamped envelope provided by
the researcher.

Informed Consent forms were matched to corresponding completed
questionnaires only through a subject identiﬁcation number. Questionnaires were coded
with a subject identiﬁcation number to protect identiﬁcation of participant responses;
neither participants’ names nor therapists’ names appeared on questionnaire responses.
Participants were asked to mail completed questionnaires to the researcher in the second
stamped envelope provided by the researcher in the survey packet.

In order to protect the privacy of participants to the maximum extent allowable by
law, the following procedures were followed regarding data obtained from participants.
Informed consent forms and the list that matches participant names with subject
identiﬁcation numbers were kept separately from all questionnaire responses in a locked
ﬁle cabinet. Questionnaire responses were kept in a separate locked ﬁle cabinet.
Questionnaire data were entered into a computer, analyzed, and stored in a password-

protected ﬁle on the researcher’s personal computer. At completion of the project, data

74

were transferred to disks, and these disks were stored in the locked cabinet together with
questionnaire responses. Data will be retained for a minimum of three years in these
secure locations and destroyed after 3 years by shredding.

Data Analyses

Data from the Help-Seeking and Treatment History Questionnaire were screened
to divide the sample into groups based on self-identiﬁcation or non-identiﬁcation as a
survivor of childhood neglect, childhood physical abuse, and childhood sexual abuse.
Participants were divided into groups based on responses to true or false questions
assessing if participants remembered being neglected, physically abused, or sexually
abused as a child. Data from the Help-Seeking and Treatment History Questionnaire
were also screened to divide the sample into groups based on the presence or history of
an eating disorder, presence or history of DSH, or presence or history of comorbid eating
disorder/DSH, independent of presence or absence of childhood abuse or neglect.
Participants were divided into groups based on responses to true/false questions about the
presence or history of an eating disorder, and a yes/no question about a history of self-
harrn. Using data from the Demographic Questionnaire and Help-Seeking and Treatment
History Questionnaire, preliminary analyses were run to adequately describe each
subgroup in terms of demographics and treatment history.

Next, to determine whether mean perfectionism scores between subgroups were
statistically signiﬁcant, multivariate analysis of variance (MAN OVA) was employed.
Due to small cell sizes, each research question was examined separately, requiring a total
of 4 separate MANOVAs. MANOVAs were used to control for inﬂated Type I error

rates due to the multiple dependent variables of interest in this study, and the high

75

correlation between dependent variables. Signiﬁcant multivariate omnibus F tests were
followed by individual univariate analyses (AN OVAs) to further delineate differences in
the nature and prevalence of perfectionism between subgroups. Finally, Tukey HSD tests
and pairwise comparisons were used to complete post hoc analyses.

Research Question 1. To determine whether mean perfectionism scores differed
based on presence of an eating disorder, presence of DSH, and presence of comorbid
eating disorder/DSH, a MANOVA was conducted using perfectionism scores as the
dependent variables and group membership (i.e. eating disorder group, DSH group,
comorbid eating disorder/DSH group) as the between-subjects factor.

Research Question 2. Childhood abuse and childhood neglect have been
repeatedly implicated in the etiology of DSH, yet little is known about the relationship
between childhood abuse, neglect, and eating disorders or the relationship between
childhood abuse, neglect, and perfectionism. Therefore, to determine whether mean
perfectionism scores differed based on self-identiﬁcation as a survivor of childhood
neglect, childhood physical abuse, or childhood sexual abuse, 3 separate MANOVAs
were conducted using perfectionism scores as the dependent variables and self-
identiﬁcation as a survivor of childhood neglect, childhood physical abuse, and childhood
sexual abuse as separate between-subjects factors. Small cell sizes prevented inclusion of

all three predictor variables in one MANOVA.

76

CHAPTER 4

Results

As a preliminary means of exploring the contribution of perfectionism in the
development and maintenance of DSH, the primary goal of the current study was to
explore the prevalence and nature of perfectionism within a DSH population compared to
an eating disorder population and comorbid eating disorder/DSH population. No
differences in the nature and prevalence of perfectionism were predicted when comparing
a DSH population, eating disorder population, and comorbid eating disorder/DSH
population. A secondary goal was to explore the possibility that within a DSH
population, eating disorder population, and comorbid eating disorder/DSH population,
individuals who self-identiﬁed as survivors of childhood abuse or childhood neglect
would exhibit differential rates of interpersonal, intrapersonal, and self-presentational
dimensions of perfectionism as compared to individuals who did not self-identify as a
survivor of childhood abuse or childhood neglect. No hypotheses were offered in regards
to the secondary goal of the study.

Preliminary analyses were conducted to assign participants to groups based on the
indication of an eating disorder, DSH, or comorbid eating disorder/DSH. Preliminary
analyses were also conducted to assign participants to groups based on a history of
childhood neglect, childhood physical abuse, and childhood sexual abuse, independent of
the initial group status (i.e. eating disorder group, DSH group, comorbid eating

disorder/DSH group). Results are addressed separately for each research question.

77

Research Question 1

Eating disorder group. The eating disorders group was composed of 38 women
ranging in age from 18 to 47 years (M= 27.08, SD = 7.16). Five participants reported a
current diagnosis of Anorexia Nervosa; 9 reported a current diagnosis of Bulimia
Nervosa; 4 reported concurrent Anorexia Nervosa and Bulimia Nervosa; 7 reported an
eating disorder not otherwise speciﬁed; 6 reported they were not sure of their diagnosis;
and 7 participants noted being in recovery. Of the 7 participants reporting recovery, 1
participant indicated recovery from Anorexia Nervosa; 3 participants reported recovering
from Bulimia Nervosa; 2 participants indicated recovering from an eating disorder not
otherwise speciﬁed; and 1 participant was unsure of her previous eating disorder
diagnosis. More than half (55.3%) of the participants in the group had received more
than one year of treatment at the time of study participation, with the majority (68.4%)
reporting that treatment had helped “a lot.” Of the remaining participants in the group, an
equal number reported feeling that treatment had either helped “a little” (15.8%) or were
“not sure” that treatment had helped. The predominant treatment modality of this group
at the time of study participation was outpatient therapy (73.7%). The presence of eating
disorder symptoms was one of the primary reasons for seeking treatment for 89.5% of the
group; 28.9% of the group had a history of hospitalization as a result of their eating
disorder. All but one had discussed her eating disorder with her therapist.

Almost half (44.7%) of the eating disorder group reported a history of neglect or
abuse at some point in their lives. A history of childhood neglect was reported most
often (28.9%), followed by a history of childhood sexual abuse (23.7%), a history of

childhood physical abuse (10.5%), a history of adult sexual assault (10.5%), and a history

78

of being physically abused as an adult (5.3%). Of the 17 women in this group who
reported a history of neglect or abuse, 6 (15.8%) noted that a history of trauma
represented one of their primary reasons for seeking treatment.

DSH group. The DSH group was composed of 13 women ranging in age from 19
to 34 years (M= 22.92 , SD= 5.15). The age of onset of DSH ranged from 7 to 19 years
(M= 15.31, SD= 4.09), with 69.2% of the group reporting an onset during the teen years.
Within the group, 23.1% of participants indicated more than 50 incidences of DSH,
46.2% indicated 21-50 incidences of DSH, and 30.8% indicated 10 or fewer incidences of
DSH. At the time of study participation, 4 of the women had received more than a year
of treatment; 4 had received six months to one year of treatment; 2 had received 1-6
months of treatment; and 3 participants had received less than one month of treatment.
The majority of women in this group (53.8%) noted that treatment had helped “a lot,”
compared to 30.8% of the group who noted that treatment had helped “a little,” 7.7% who
were “not sure” how helpful treatment had been, and 7.7% who noted that treatment had
“not at all” been beneﬁcial. The predominant treatment modality of this group at the time
of study participation was outpatient therapy (84.6%). The majority of women in this
group (61.5%) reported that DSH represented a primary reason for seeking treatment, and
3 of the 13 women had been hospitalized at some point in time as a result of DSH. All of
the participants had discussed DSH with their therapist.

The majority of the DSH group (69.2%) reported a history of neglect or abuse at
some point in their lives. A history of childhood physical abuse was reported most often
(46.2%), followed by a history of childhood sexual abuse (30.8%) and sexual assault

during adulthood (30.8%). A history of childhood neglect (7.7%) or history of physical

79

assault during adulthood (7.7%) was reported least often. Of the 9 women in this group
reporting a history of neglect or abuse, 4 (30.8%) noted a history of trauma as one of the
primary reasons for seeking treatment.

Comorbid eating disorder/DSH group. The comorbid ED/DSH group was
composed of 34 women ranging in age from 19 to 48 years (M= 29.68, SD= 8.95). The
age of onset of DSH ranged from 5 to 22 years (M= 14.50, SD= 4.14), with 71.6% of the
group reporting an onset during the teen years. Within the group, 23.5% of participants
indicated more than 50 incidences of DSH; 26.5% indicated 21-50 incidences of DSH;
17.6% indicated 11-20 incidences of DSH; and 32.4% indicated 10 or fewer incidences
of DSH. Ten of the 34 group participants reported a current Anorexia Nervosa
Diagnosis; 7 reported a current Bulimia Nervosa diagnosis; 3 reported a concurrent
Anorexia Nervosa/Bulimia Nervosa diagnosis; 3 reported an eating disorder not
otherwise speciﬁed diagnosis; and one participant was unsure of her diagnosis. Ten
participants in this group indicated they were in recovery. One participant reported
recovery from Anorexia Nervosa; 3 participants reported recovery from Bulimia
Nervosa; 3 participants reported recovery from concurrent Anorexia Nervosa and
Bulimia Nervosa; 2 participants reported recovery from an eating disorder not otherwise
speciﬁed; and l participant was unsure of her past eating disorder diagnosis.

More than half (55.9%) of the participants in this group had received more than a
year of treatment at the time of study participation, with 70.6% of the group reporting
that treatment had helped “a lot.” In comparison, 29.4% of the group reported that
treatment had helped “a little.” The predominant modality of treatment at the time of

study participation was outpatient therapy (64.7%). The presence of eating disorder

80

symptoms was one of the primary reasons for seeking treatment for 61.8% of the group,
and 35.3% of the group reported a history of hospitalization as a result of an eating
disorder. All but one of the group participants had discussed their eating disorder with
their therapist. In comparison, the presence of DSH was one of the primary reasons for
seeking treatment for only 26.5% of the group, but 35.3% reported a history of
hospitalization as a result of DSH. Ten of the 34 group participants had never discussed
DSH with their therapist.

The majority of the comorbid EDfDSH group (88.2%) reported a history of
neglect or abuse at some point in their lives. A history of childhood neglect was reported
by 50 % of the group; a history of sexual assault during adulthood was also reported by
50% of the group. A history of childhood sexual abuse was reported by 44.1% of the
group, and a history of childhood physical abuse was reported by38.2% of the group. A
history of physical abuse during adulthood was reported by 32.4 % of the group. Of the
30 women in this group reporting a history of neglect or abuse, 13 women (38.2%)
indicated that a history of trauma represented one of the primary reasons for seeking
treatment.

Perfectionism analyses by group . MANOVA was conducted to determine
whether the above three groups differed on mean perfectionism scores. Group status
served as the predictor variable and mean perfectionism scores were the dependent
variables. Group means and standard deviations for each of the perfectionism variables

are presented in Table 2.

81

Table 2
Means and Standard Deviations by Diagnostic Group

 

 

Eating disorders DSH Comorbid
group group 8T 0111’
(n= 36) (n= 13) (n= 32)
Perfectionism variable M SD M SD M SD
Trait perfectionism
SOP 85.63 15.93 74.00" 15.51 86.38 15.93
SPP 64.75 13.20 62.54 14.15 69.31 17.21
OOP 56.14 14.11 59.31 12.75 56.44 16.38
Self-presentational perfectionism
Self-promotional perfectionism 55.81 8.80 44.46" 12.06 56.16 8.87
Nondisplay of imperfection 53.28 10.51 49.62" 11.41 58.97 8.02
Nondisclosure of imperfection 32.42 9.62 32.00 8.47 34.56 7.89
Total perfectionism 102.39 16.31 93.23“ 17.58 110.59 15.60

 

Note. SOP= self-oriented perfectionism; SPP= Socially prescribed perfectionism; OOP= Other-oriented
perfectionism. "Indicates signiﬁcant differences between the DSH group and the comorbid eating
disorder/DSH group. "Indicates signiﬁcant differences between the DSH group and both the eating
disorder group and comorbid eating disorder/DSH group.

MANOVA assumptions were checked prior to beginning the analyses. Two
outliers were found in the eating disorder group and two outliers were found in the
comorbid eating disorder/DSH group; these outliers were dropped from subsequent
analyses. Six of the 7 perfectionism variables initially met the assumption of normality;
self-oriented perfectionism scores were slightly negatively skewed and were therefore
transformed. Levene’s Test of Equality of Error Variances was nonsigniﬁcant for each of
the 7 perfectionism variables, therefore indicating equality of error variances. However,
Box’s M Test of Equality of Covariance Matrices was signiﬁcant, F (56, 4530) = 1.82,
p<.001. As a result, Pillai’s Trace test statistic was chosen because of its robustness in
face of violations of the equality of covariances assumption. Additionally, a signiﬁcance
level of Alpha= .01 was used for all statistical tests. A Sidak adjustment was applied to
all post-hoe tests due to the number of multiple comparisons.

Initial MANOVA results showed a signiﬁcant multivariate effect for group status,

Pillai’s Trace =.510, approximate F (14, 146) = 3.57, p<.01, npz =.255. In order to explain

82

the differences among groups on mean perfectionism scores, univariate analyses of
variance (ANOVA) were conducted. Signiﬁcant univariate results were found for self-
promotional perfectionism, F (2,78)= 8.184, p<.01, npz = .173; nondisplay of
imperfection, F (2,78)= 5.1901, p<.01, npz =.117; self-oriented perfectionism,
F(2,78)=6.017, p<.01, npz =.134; and the total perfectionism score, F(2,78)=5.748, p<.01,
npz = .128. Tukey’s HSD post-hoe tests revealed that the mean self-promotional
perfectionism scores of the DSH group (M= 44.46, SD= 12.06) were signiﬁcantly lower
compared to the mean self-promotional perfectionism scores of the eating disorders
group (M= 55.81, SD= 8.80) and the comorbid eating disorder/DSH group (M= 56.16,
SD= 8.87). Similarly, mean self-oriented perfectionism scores of the DSH group
(M=74.00, SD= 15.51) were signiﬁcantly lower than the mean self-oriented
perfectionism scores of the eating disorder group (M=85.63, SD= 15.93) and the
comorbid eating disorder/DSH group (M=86.38, SD= 15.93). No signiﬁcant differences
were found between the eating disorder group or comorbid eating disorder/DSH group on
either mean self-promotional perfectionism scores or mean self-oriented perfectionism
scores.

Tukey HSD post-hoc tests also revealed signiﬁcantly lower nondisplay of
imperfection mean scores for the DSH group (M=49.62, SD= 11.41) compared to the
comorbid eating disorder/DSH group (M=58.97, SD= 8.02), but the DSH group mean
score did not signiﬁcantly differ from the eating disorder group mean score (M= 53.28,
SD= 10.51) and the eating disorder group mean score and comorbid group mean score
did not signiﬁcantly differ from one another. An identical pattern was found when

examining total perfectionism scores. The DSH group exhibited signiﬁcantly lower

83

mean total perfectionism scores (M= 93.23, SD= 17.58) compared to the comorbid eating
disorder/DSH group, but the DSH group mean total perfectionism score did not differ
signiﬁcantly from the eating disorder group mean total perfectionism score (M=102.39,
SD= 16.31) and the eating disorder group and comorbid eating disorder/DSH group did
not signiﬁcantly differ from one another.
Research Question 2

Of the total sample of 85 participants, 40 participants reported no history of
childhood neglect, childhood sexual abuse, or childhood physical abuse; 9 participants
reported a history of all 3 types of childhood trauma. Seven participants reported a
history of childhood neglect alone; 7 participants reported a history of childhood sexual
abuse alone; and 5 participants reported a history of childhood physical abuse alone.
Nine participants reported a history of both childhood neglect and childhood sexual
abuse; 4 participants reported both a history of childhood neglect and childhood physical
abuse; and 4 participants reported both a history of childhood sexual abuse and childhood
physical abuse. The small cell sizes prevented an analyses of potential interaction effects
between childhood neglect, childhood sexual abuse, and childhood physical abuse.
Therefore, main effects for childhood neglect, childhood sexual abuse, and childhood
physical abuse were examined by conducting separate MANOVAs. MANOVA
assumptions were checked prior to beginning the analyses. Four outliers were found and
dropped from subsequent analyses. Three of the 7 perfectionism variables initially met
assumptions of normality. Self-promotional perfectionism scores, Other-oriented
perfectionism scores, and total perfectionism scores were slightly negatively skewed for

each predictor variable. Socially prescribed perfectionism scores were slightly positively

84

skewed for each predictor variable. Therefore, these 4 perfectionism variables were
transformed. Box’s Test of Equality of Covariance Matrices was nonsigniﬁcant for each
of the 3 MANOVAs, therefore indicating equality of covariances. Levene’s Test of
Equality of Error Variances was nonsigniﬁcant for the dependent variables of each
MANOVA with the following exceptions. Levene’s Test of Equality of Error Variances
was signiﬁcant for total perfectionism scores with childhood neglect as a predictor and
with childhood physical abuse as a predictor, F(1,79)= 5.21, p<.05, F (1 ,79) = 10.57,
p<.05, respectively. Levene’s Test of Equality of Error Variances was also signiﬁcant for
socially prescribed perfectionism scores with childhood neglect as a predictor, F (1 ,79)=
5.32, p<.05. As a result, Pillai’s Trace test statistic was chosen because of its robustness
in face of violations of the equality of error variances assumption. A signiﬁcance level of
Alpha= .01 was used for each MANOVA. A Sidak adjustment was applied to all
pairwise comparisons due to the number of multiple comparisons. A signiﬁcance level of
Alpha= .05 was used for all pairwise comparisons.

Childhood neglect. Of the total sample of 85 participants, 29 participants self-
identiﬁed as a childhood neglect survivor compared to 56 participants who did not self-
identify as a childhood neglect survivor. The mean age of neglect survivors was 32.01
years (SD= 8.8), compared to 25.11 years (SD= 6.29) for participants who did not self-
identify as a childhood neglect survivor. The majority of participants who self-identiﬁed
as a childhood neglect survivor were drawn from the comorbid eating disorder/DSH
group (58.6%), followed by the eating disorder group (37.9%) and the DSH group

(3.4%).

85

MANOVA was conducted to determine whether mean perfectionism scores

differed based on self-identiﬁcation as a survivor of childhood neglect. Group status (ie.

self-identiﬁcation as a childhood neglect survivor, no self-identiﬁcation as a childhood

neglect survivor) served as the predictor variable and perfectionism scores were the

dependent variables. Group means and standard deviations for each of the perfectionism

variables are presented in Table 3.

Table 3

Means and Standard Deviations by Childhood Neglect History

Childhood neglect No Childhood neglect Signiﬁcance

 

(n= 26) (n= 55) of difference
Perfectionism variable M SD M SD between means
Trait perfectionism
Self-oriented perfectionism 90.88 11.60 83.98 11.83 .02"
Socially prescribed perfectionism 70.69 17.62 64.47 12.97 .10
Other-oriented perfectionism 52.42 17.51 59.18 12.46 .12
Self-presentational Perfectionism
Self-promotional perfectionism 57.34 9.04 53.01 9.73 .06
Nondisplay of imperfection 57.65 9.57 53.76 10.14 .1 1
Nondisclosure of imperfection 35.19 9.83 32.33 8.03 .17
Total perfectionism 1 13.00 17.05 100.96 14.01 .001 "

 

*p <.05

Initial results showed a signiﬁcant multivariate effect for group status, Pillai’s
Trace =.27o, approximate F(7, 73) = 3.85, p<.01, npz =.27o. In order to explain the
differences among groups on mean perfectionism scores, univariate analyses of variance
(ANOVA) were conducted. Signiﬁcant univariate results were found for self-oriented
perfectionism, F (1 ,79)=6.082, p<.05, npz =.O7l, and the total perfectionism score,
F (1 ,79)=12.83, p<.05, 1],} = .140. Pairwise comparisons revealed that childhood neglect
survivors exhibited signiﬁcantly higher self-oriented perfectionism mean scores (M=
90.88, SD= 11.60) compared to participants who did not identify as childhood neglect
survivors (M= 83.98, SD= 11.83). Additionally, pairwise comparisons revealed that

childhood neglect survivors exhibited signiﬁcantly higher total perfectionism mean

86

scores (M= 113.00; SD= 17.05) compared to participants who did not identify as
childhood neglect survivors (M=100.96, SD= 14.01).

Childhood sexual abuse. Of the total sample of 85 participants, 28 participants
self-identiﬁed as a childhood sexual abuse survivor compared to 57 participants who did
not self-identify as a childhood sexual abuse survivor. The mean age of sexual abuse
survivors was 32.61 years (SD= 8.31), compared to 24.96 years (SD= 6.46) for
participants who did not self-identify as a childhood sexual survivor. The majority of
participants who self-identiﬁed as a childhood sexual survivors were drawn from the
comorbid ED/DSH group (53.6%), followed by the eating disorder group (32.1%) and
the DSH group (14.3%).

MAN OVA was conducted to determine whether mean perfectionism scores
differed based on self-identiﬁcation as a survivor of childhood sexual abuse. Group
status (ie. self-identiﬁcation as a childhood sexual abuse survivor, no self-identiﬁcation
as a childhood sexual abuse survivor) served as the predictor variable and perfectionism
scores were the dependent variables. Group means and standard deviations for each of

the perfectionism variables are presented in Table 4.

 

 

Table 4
Means and Standard Deviations by Childhood Sexual Abuse History
Childhood No childhood Signiﬁcance of
sexual abuse sexual abuse difference between
(n= 25) (n=56 ) means
Perfectionism variable M SD M SD
Trait perfectionism
Self-oriented perfectionism 87.04 12.38 85.82 12.1 1 .68
Socially prescribed perfectionism 71.56 14.46 64.20 14.51 .75
Other-oriented perfectionism 57.48 15.12 56.80 14.38 .04"
Self-presentational perfectionism
Self-promotional perfectionism 55.72 7.22 53.82 10.59 .73
Nondisplay of imperfection 56.92 9.25 54.16 10.38 .26
Nondisclosure of imperfection 35.20 7.85 32.37 8.96 .18
Total perfectionism 107.52 14.09 103.63 16.73 .41

 

*p<.05

87

Initial results showed a nonsigniﬁcant multivariate effect for group status, Pillai’s
Trace = .104, approximate F (7, 73) = 1.216, p>.05, npz = .104. Given the exploratory
nature of this study, univariate analyses of variance (ANOVA) were conducted to
identify potential areas for future research, despite the nonsigniﬁcant omnibus
multivariate F test. Signiﬁcant univariate results were found for Socially Prescribed
Perfectionism, F (1,79) = 4.49, p<.05, rip2 = .054. Pairwise comparisons revealed that
childhood sexual abuse survivors exhibited signiﬁcantly higher socially prescribed
perfectionism mean scores (M= 71.56, SD= 14.46) compared to participants who did not
identify as childhood sexual abuse survivors (M= 64.20, SD= 14.51). However, given the
nonsigniﬁcant omnibus multivariate F test, this result should be interpreted with
appropriate caution.

Childhood physical abuse. Of the total sample of 85 participants, 23 participants
self-identiﬁed as a childhood physical abuse survivor compared to 62 participants who
did not self-identify as a childhood physical abuse survivor. The mean age of childhood
physical abuse survivors was 28.96 years (SD= 8.83), compared to 26.94 years (SD=
7.59) for participants who did not self-identify as childhood physical abuse survivors.
The majority of participants who self-identiﬁed as a childhood physical survivor were
drawn from the comorbid ED/DSH group (56.5%), followed by the DSH group (26.1%)
and the eating disorder group (17.4%).

MANOVA was conducted to determine whether mean perfectionism scores
differed based on self-identiﬁcation as a survivor of childhood physical abuse. Group
status (ie. self-identiﬁcation as a survivor of childhood physical abuse, no self-

identiﬁcation as a survivor of childhood physical abuse) served as the predictor variable

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and perfectionism scores were the dependent variables. Group means and standard

deviations for each of the perfectionism variables are presented in Table 5.

 

 

 

Table 5
Means and Standard Deviations by Childhood Physical Abuse History
Childhood No childhood Signiﬁcance of
physical abuse physical abuse difference
(n= 22 ) (n= 59) between means
Perfectionism variable M SD M SD
Trait perfectionism
Self-oriented perfectionism 87.36 12.23 85.76 12.16 .60
Socially prescribed perfectionism 73.86 15.34 63.71 13.73 .01“
Other-oriented perfectionism 55.68 17.75 57.51 13.26 .89
Self-presentational perfectionism
Self-promotional perfectionism 57.36 8.00 53.31 10.07 .14
Nondisplay of imperfection 58.00 8.567 53.90 10.42 .10
Nondisclosure of imperfection 36.59 8.04 32.00 8.65 .03"
Total perfectionism 107.82 19.59 103.71 14.44 .15
I"p <.05

Initial results showed a nonsigniﬁcant multivariate effect for group status, Pillai’s
Trace = .146, approximate F (7, 73) = 1.216, p>.05, npz = .146. Given the exploratory
nature of this study, univariate analyses of variance (ANOVAs) were conducted to
identify potential areas for future research, despite the nonsigniﬁcant omnibus
multivariate F test. Signiﬁcant univariate results were found for socially prescribed
perfectionism, F (1,79) = 7.89, p<.05, npz = .091 , and nondisclosure of imperfection,
F (1,79) = 4.68, p<.05, m,2 = .056. Pairwise comparisons revealed that childhood physical
abuse survivors exhibited signiﬁcantly higher socially prescribed perfectionism mean
scores (M= 73.86, SD= 15.34) compared to participants who did not identify as childhood
physical abuse survivors (M= 63.71, SD= 13.73). Pairwise comparisons also revealed
that childhood physical abuse survivors exhibited signiﬁcantly higher nondisclosure of
imperfection mean scores (M= 36.59, SD= 8.04) compared to participants who did not

identify as childhood physical abuse survivors (M= 32.00, SD= 8.65). However, given

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the nonsigniﬁcant omnibus multivariate F test, these result should be interpreted with
appropriate caution.

CHAPTER 5

Discussion

The primary goal of this study was to explore the prevalence and nature of
perfectionism within a DSH population. Anecdotal reports have suggested that
perfectionism is a common characterological trait among individuals who engage in
DSH, but the relationship between DSH and perfectionism had not been examined
empirically prior to the current study. An eating disorder population and comorbid
eating disorder/DSH population were used as control groups due to the theoretical and
empirical links that have been established between DSH and eating disorders, and
between eating disorders and perfectionism, as well as the lack of reliable and valid DSH
assessment instruments. No differences in the nature and prevalence of perfectionism
were predicted when comparing a DSH population, eating disorder population, and
comorbid eating disorder/DSH population. The results of this study partially supported
this hypothesis. A comparison of the groups on the separate perfectionism variables
found commonalities between groups, but also revealed several signiﬁcant differences
between groups.
Diﬂerences in Dimensions of Perfectionism

Higher levels of total perfectionism were found in the comorbid eating
disorder/DSH group compared to the DSH group, yet no signiﬁcant differences emerged

between the eating disorder group and DSH group or the eating disorder group and

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comorbid eating disorder/DSH group on total perfectionism. This ﬁnding illustrates the
importance of examining perfectionism from a multidimensional perspective and
examining intrapersonal and interpersonal dimensions of perfectionism separately. As
the total perfectionism score collapses intrapersonal and interpersonal dimensions of
perfectionism, this ﬁnding suggests that certain dimensions of perfectionism may be
more prevalent in either an eating disorder population or DSH population.

Self-concept plays a pivotal role in self-oriented perfectionism and socially
prescribed perfectionism. Both dimensions of perfectionism involve perfectionistic
expectations directed at the self, but the distinction involves the source of perfectionistic
expectations. Self-oriented perfectionism involves self-imposed standards of
perfectionism. Socially prescribed involves the perception that others expect one to be
perfect. In contrast, other-oriented perfectionism is other-focused rather than self-
focused. In the present study, both the eating disorder and comorbid eating disorder/DSH
groups exhibited signiﬁcantly higher self-oriented perfectionism scores compared to the
DSH group, but the eating disorder group and comorbid eating disorder/DSH group did
not differ from one another. In other words, self-oriented perfectionism was most
pronounced when an eating disorder was present. However, no signiﬁcant differences
emerged between any of the three groups on socially prescribed perfectionism or other-
oriented perfectionism, both considered interpersonal dimensions of perfectionism.
Although it is possible that low study power failed to reveal existing differences, this
ﬁnding suggests commonalities between populations in terms of perceptions of others’
expectations and expectations of others. This pattern of ﬁndings suggests that whereas

eating disorder symptoms may be driven by the desire to meet self-imposed unrealistic

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standards, issues common to both eating disorders and DSH, such as low self-esteem,
fear of criticism, and fear of rejection, may be driven by a feelings that one is not meeting
the standards perceived to be set by others (Goldner et al., 2002). These distinctions are
relevant to understanding the potential differential relationships between perfectionism
and self-concept within a DSH population compared to an eating disorder population.
Previous research has found self-oriented perfectionism to be driven by a need for
achievement, and socially prescribed to be driven by a fear of failure. The ﬁndings from
the present study suggests the self-concept of women struggling with DSH is similarly
affected by the perceived perceptions and expectations of others, and similar to an eating
disorder population, fear of failure may be a prominent characteristic of the DSH
population. However, the DSH population may be less driven by a need for achievement
compared to an eating disorder and comorbid eating disorder/DSH population. Instead,
perfectionistic expectations within a DSH population, in the absence of an eating
disorder, appear to be interpersonally driven by the need to be accepted as well as the
need to avoid criticism from others. The self-presentational perfectionism ﬁndings from
this study support this proposition.

A growing body of research has demonstrated a relationship between
perfectionistic self-presentation and eating disorders (Goldner et al., 2002), but
perfectionistic self-presentation has never been previously explored in a DSH population.
Previous research has found that a clinical sample of women with eating disorders
exhibited stronger needs to avoid disclosing imperfection, avoid displaying imperfection,
and stronger needs to present an image of perfection to others compared to women with

other Axis I diagnoses (Cockell etal., 2002). Consistent with the results found by

92

Cockell et al. (2002), the results of the present study found signiﬁcantly higher levels of
self-promotional perfectionism in the eating disorder group and comorbid eating
disorder/DSH group compared to the DSH group, suggesting stronger needs to actively
display one’s accomplishments, goals, and aspirations among women when an eating
disorder is present. However, the present study revealed no signiﬁcant differences
between the eating disorders group and the DSH group, or the eating disorder group and
comorbid eating disorder/DSH group on nondisplay of imperfection. Nondisplay of
imperfection speciﬁcally refers to a perfectionistic self-presentational style involving the
concealment of imperfections. The only signiﬁcant difference to emerge between groups
on nondisplay of imperfection scores emerged between the DSH group and comorbid
eating disorder/DSH group; the comorbid eating disorder/DSH group exhibited
signiﬁcantly higher levels of nondisplay of imperfection compared to the DSH group. In
contrast, the results of this study found no signiﬁcant differences between the DSH
group, eating disorders group, or comorbid eating disorder/DSH group on nondisclosure
of imperfection, a perfectionistic self-presentation style involving the avoidance of verbal
disclosures of imperfection. Taken together, this pattern of ﬁndings suggests that women
who self-harm may possess a level of reluctance to verbally self-disclose or display self-
perceived imperfections similar to that of women with eating disorders, but women who
self-harm in the absence of an eating disorder are less likely than women with an eating
disorder to actively promote the appearance of competence and success, regardless of the
presence or absence of self-harm.

In summary, no signiﬁcant differences emerged between the eating disorder

group and the comorbid eating disorder/DSH group on any of the dimensions of trait

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perfectionism or self-presentational perfectionism, but these groups exhibited
signiﬁcantly elevated self-oriented perfectionism and self-promotional perfectionism
compared to the DSH group. It is plausible that a unique relationship exists between
intrapersonal perfectionism and eating disorders, as supported by the ﬁnding that self-
oriented perfectionism was signiﬁcantly elevated within the DSH population when an
past or present history of an eating disorder was also present. This hypothesis is
supported by past research in which Hewitt et al. (1995) found a speciﬁc relationship
between eating disorder symptomatology and self-oriented perfectionism.

The secondary goal of this study was to explore the possibility that within a DSH
population, eating disorder population, and comorbid eating disorder/DSH population,
individuals who self-identiﬁed as survivors of childhood abuse or childhood neglect
would exhibit differential rates of interpersonal, intrapersonal, and self-presentational
dimensions of perfectionism compared to individuals who did not self-identify as a
survivor of childhood abuse or neglect. No hypotheses were offered in regards to the
secondary goal of the study as research has yet to empirically examine the relationship
between different dimensions of perfectionism and childhood trauma. However,
exposure to neglect, abuse, and shaming situations have each been theorized to
individually and interactively foster the development of perfectionism.

When all of the dimensions of perfectionism were examined simultaneously for
each of the indicators of childhood trauma, the only signiﬁcant differences to emerge
involved childhood neglect. Signiﬁcant differences were revealed between self-identiﬁed
childhood neglect survivors and women reporting no history of childhood neglect on total

perfectionism scores and self-oriented perfectionism. Given that 4 of the 6 subscales

94

associated with the total perfectionism score are intrapersonal in nature, it is not
surprising that the total perfectionism scores and self-oriented perfectionism scores were
similarly elevated. While the social reaction model of perfectionism suggests that
perfectionism develops in response to being raised in a harsh environment characterized
by hostility or lack of warmth (F lett et al., 2002), the model does not adequately explain
why differences emerged in an intrapersonal dimensional of perfectionism and not in
interpersonal or self-presentational dimensions of perfectionism. Yet, as noted by F lett et
a1. (2002), adults in treatment have reported adopting perfectionism in response to
parental neglect, and Hamachek (1978) notes that perfectionism may develop in the
absence of parental expectations. Without clear parental expectations and standards, it
can be hypothesized that neglected children self-impose standards of perfection in order
to attempt to gain attention from neglectful parents or avoid punishment (Flett et al.,
2002)

No signiﬁcant differences emerged when comparing self-identiﬁed childhood
sexual abuse survivors to women reporting no history of childhood sexual abuse when
examining all of the perfectionism dimensions under study simultaneously. Similarly, no
signiﬁcant differences emerged when comparing self-identiﬁed childhood physical abuse
survivors to women reporting no history of childhood physical abuse when examining all
of the perfectionism dimensions under study simultaneously. However, in an effort to
identify speciﬁc areas for future research, each of the dimensions of perfectionism was
examined separately.

Prior research, using a unidimensional conceptualization of perfectionism, has

indicated higher levels of perfectionism among female college students with a history of

95

sexual abuse or physical abuse compared to nonabused female college students (Schaaf &
McCane, 1994). While both abuse groups exhibited higher scores, only the physically
abused group exhibited signiﬁcantly higher scores. Similarly, in a clinical sample,
Zlotnick et al. (1996) found higher levels of perfectionism among women with a history
of sexual abuse compared to nonabused women, but again, a unidimensional measure of
perfectionism was utilized. In the only study found to speciﬁcally address the
relationship between perfectionism and abuse in an eating disorder population, bulimic
women with a history of physical battery were found to exhibit higher levels of
perfectionism on a unidimensional measure of perfectionism compared to bulimic women
with no history of physical battery. Interestingly, given the results of prior studies, no
differences were found on total levels of perfectionism for either childhood sexual abuse
or childhood physical abuse. However, higher levels of socially prescribed perfectionism
were found in childhood sexual abuse survivors compared to women reporting no history
of childhood sexual abuse, and higher levels of socially prescribed perfectionism were
found in childhood physical abuse survivors compared to women reporting no history of
childhood physical abuse. Additionally, childhood physical abuse survivors exhibited
higher levels of nondisclosure of imperfection compared to women reporting no history
of childhood physical abuse. Although caution is warranted given the nonsigniﬁcant
multivariate effects, these ﬁndings suggest the need for continued study of the
relationships between childhood abuse and different dimensions of perfectionism in
general, and continued study of the relationships between childhood abuse and different
dimensions of perfectionism in the DSH population and eating disorder population in

particular.

96

Implications of ﬁndings

The present study has implications for therapists working with clients with DSH
and comorbid eating disorder/DSH, as well as clients with eating disorders. In terms of
assessment, the high comorbidity rate between DSH and eating disorders established in
this study and elsewhere necessitates a thorough assessment of both DSH and eating
disorder symptoms when a client presents with either of these concerns. The high levels
of self-reported childhood neglect and childhood abuse in this study also supports the
importance of completing a detailed assessment of childhood experiences when a client
presents with DSH or eating disorder concerns.

Clinically, perfectionism may be more obvious in an eating disorder client or
client with comorbid eating disorder/DSH concerns than a client with DSH alone through
self-promotion of perfectionism, but the astute clinician should be attuned to client
feedback indicating high levels of socially prescribed perfectionism. The similar levels
of socially prescribed perfectionism found between the populations in this study, in
conjunction with previous research indicating signiﬁcant associations between elevated
levels of socially prescribed perfectionism and disordered eating (Cockell et al., 2002;
Hewitt et al., 1995; McVey et al., 2002), suggests socially prescribed perfectionism is
prevalent in a DSH population. Neilson et al. (1997) found that perfectionism was
positively related to decreased openness about personal issues and less tolerance for the
stigma associated with seeking professional help; these relationships were strongest for
socially prescribed perfectionism (as cited in Habke & Flynn, 2002). Socially prescribed
perfectionists often feel socially inadequate (Flett, Hewitt, & DeRosa, 1996), fear

criticism, and fear appearing foolish to others (Blankstein, Flett, Hewitt, & Eng, 1993).

97

Hewitt et al. (2003) reported a negative association between comfort in seeking help and
socially prescribed perfectionism, as well as a positive relationship between difficulty
continuing treatment and socially prescribed perfectionism, thus indicating that socially
prescribed perfectionism may signiﬁcantly impede the treatment of clients with eating
pathology or DSH.

Additionally, while DSH clients may not evidence self-promotional perfection
levels and self-oriented perfectionism levels to the same degree as eating disorder clients,
similar levels of nondisclosure of imperfection and nondisplay of imperfection have
signiﬁcant implications for the therapeutic relationship. These self-presentation styles
may not only decrease the likelihood of initial help-seeking behaviors, but may also
increase the likelihood of premature termination of treatment. According to Flett &
Hewitt (2002), “High levels of perfectionistic self-presentation in the context of therapy
may undermine treatment because the client may be unwilling to reveal intimate aspects
of his or her self; that reluctance contributes to the experience of distress and undermines
the treatment process” (p. 26). Preliminary evidence suggests a signiﬁcant association
between perfectionism and a distressing experience of the therapeutic relationship (Habke
& Flynn, 2002). Speciﬁc issues that may arise include a client’s attempt to be the
“perfect” client and the perception that the therapist is placing excessive expectations of
recovery on the client, inevitably leaving the client feeling like a failure if progress does
not occur quickly enough or if a relapse of symptoms occurs. Additionally,
perfectionistic clients may need assistance recognizing small gains in therapy rather than

employing “all or nothing” thinking to judge the success of treatment.

98

Although there is a paucity of research addressing the treatment of perfectionism,
limited evidence suggests the efﬁcacy of a psychodynamic, interpersonal approach that
targets the interpersonal needs driving perfectionism, such as a fear of rejection and a
need for approval, and targeting the process-related variables associated with
perfectionism rather than targeting perfectionistic behavior itself (Hewitt et al., 2001).
While research has failed to address the efﬁcacy of different approaches in the treatment
of DSH, this approach is consistent with the literature supporting the efﬁcacy of
interpersonal treatment approaches in an eating disorder population (Fairbum, 1997).
Cognitive-behavioral approaches have also been found to be efﬁcacious in the treatment
of eating disorders (Fairbum, 1997; Garner, Vitousek, & Pike, 1997; Johnson & Conners,
1987), and are commonly incorporated into the treatment of DSH (Conterio & Lader,
1998). When treating DSH and eating disorders alone or concurrently, it may be helpful
to employ cognitive behavioral approaches to decrease speciﬁc DSH and eating disorder
behaviors, and simultaneously incorporate interpersonal techniques to address the
interpersonal functions of the behaviors and underlying personality traits, such as
perfectionism (Levitt, Sansone, & Cohn, 2004). Regardless of the treatment approach
taken, this study underscores the importance of assessing perfectionism from a
multidimensional perspective in a DSH, eating disorder, or comorbid eating
disorder/DSH population in order to ascertain the source and target of perfectionistic
expectations, thus allowing for interventions to be tailored accordingly.

Limitations
The results of the present study must be interpreted in the context of several

important limitations, including limitations associated with the design and internal

99

validity of the study, external validity and generalizability, and analyses and statistical
power. First, the design of the study prevented causal statements from being made.
Second, potentially signiﬁcant differences within each population were not examined or
controlled for in the analyses. For example, the duration and severity of DSH among
participants were not considered in the analyses, and speciﬁc eating disorder diagnoses
were not examined separately. Furthermore, within the comorbid eating disorder/DSH
group, the onset of an eating disorder in comparison to the onset of DSH was not
examined. Imprecise measurement of childhood abuse and neglect limited the results as
well. While the use of categorical data indicating group membership may have disguised
within group differences, this study was intended to be exploratory in nature; results
should be generalized with appropriate precaution.

Generalizability of the ﬁndings is limited due to the small sample size, the use of
a nonrandom sample of volunteers, the use of a clinical population obtained from a
restricted geographical area, and the utilization of therapists’ assistance in selecting
appropriate participants in order to minimize risk. The method of recruitment utilized in
this study did not allow the researcher to determine the number of individuals who chose
not to participate when presented with the opportunity; thus, important but unknown
characteristics may have distinguished those individuals choosing to participate from the
larger populations under study. Additionally, by informing potential participants that
perfectionism was the focus of the study, it is possible that a response bias was
introduced. Reliance on self-report data may have also affected the results.

Finally, although attempts were made to adjust for violations of MANOVA

assumptions, it should be reiterated that violations did occur. The assumption of equality

100

of covariance matrices was violated when multivariate effects were examined with
membership in a DSH group, eating disorder group, and comorbid eating disorder/DSH
group as the predictor. The assumption of equality of error variances was violated for
total perfectionism scores with childhood neglect as a predictor and with childhood
physical abuse as a predictor, and with socially prescribed perfectionism scores with
childhood neglect as a predictor.

Despite these limitations, the present study makes a number of contributions to
the existing empirical literature and has important implications for clinical practice. To
date, this is the ﬁrst empirical study to provide evidence of perfectionism in a group of
women who deliberately self-harm. Future studies are needed to determine more fully
whether perfectionism represents a speciﬁc risk factor for DSH. The present study is
also among the ﬁrst to empirically examine the relationship between indices of childhood
trauma and different dimensions of perfectionism. Again, continued inquiry is needed to
further delineate the relationships between speciﬁc types of childhood trauma and
different dimensions of perfectionism, but the present study should serve as a foundation
for future studies. Finally, this study extends the research on multidimensional
perfectionism within an eating disorder population. The results of this study clearly
support the importance of examining perfectionism from a multidimensional perspective.
Directions for Future Research

The study was initially designed to examine whether self-identiﬁcation as a
childhood abuse and/or neglect survivor interacted with group status (i.e. DSH group,
eating disorder group, comorbid DSH/ED group) in the relationships between group

status and various dimensions of perfectionism. However, small cell sizes prevented an

101

examination of potential interaction effects. Given the signiﬁcant differences found in
dimensions of perfectionism when group status, childhood abuse, and childhood neglect
were examined separately, it will be important for future studies to continue to address
whether differences in perfectionism exist among women with DSH and/or eating
disorders based on histories of abuse and neglect. Additionally, future research is needed
to clarify whether childhood sexual abuse, childhood physical abuse, and childhood
neglect interact to predict perfectionism. To date, minimal research has addressed the
relationship between childhood abuse and neglect and perfectionism. Utilization of non-
categorical measures of abuse and neglect will be capable of providing a more in-depth
exploration of these relationships.

Although the present study provides preliminary empirical evidence of elevated
levels of perfectionism within a DSH population, the ﬁndings of this study need to be
replicated in larger samples, particularly since a large number of analyses were
performed in a relatively small sample, thus limiting power. Finally, whereas the primary
interest of the current study was to determine the nature and prevalence of perfectionism
with a DSH population, additional research is needed to explore the role of different
dimensions of perfectionism in the development and maintenance of DSH. DSH and
perfectionism are both complex phenomena; in order for counseling psychologists to
successfully treat perfectionistic women who self-harm, attention must be given to the
ways in which speciﬁc perfectionistic expectations have inﬂuenced the initiation and

perpetuation of self-harm behavior.

102

APPENDICES

103

APPENDIX A

Request for Therapist Assistance

Thank you for your potential assistance and cooperation with this research project. This
project is being conducted by Anne Kubal, a doctoral candidate in Counseling
Psychology at Michigan State University, under the supervision of Dr. Nancy Crewe, a
professor in the Department of Counseling, Educational Psychology, and Special
Education at Michigan State University.

One of my goals as a psychologist-in-training is to work with other professionals to
improve the treatment experiences of women who seek help for eating disorders and/or
deliberate self-harm (i.e. self-injury) through research that is speciﬁcally relevant to
treatment. The purpose of this investigation is to learn more about the nature and
prevalence of perfectionistic tendencies among women who have sought psychological or
psychiatric help for deliberate self-harm, eating disorders, or both of these issues. For the
purposes of this study, deliberate self-harm or self-injury is deﬁned as the deliberate
destruction or alteration of one’s own body, performed without suicidal intent. Examples
of deliberate self-harm include cutting oneself, burning oneself, biting oneself, head-
banging, interfering with the healing of wounds, or scratching until one bleeds. For the
purpose of this study, deliberate self-harm DOES NOT include excessive drinking of
alcohol or overdosing on drugs.

You have received this request for assistance because you have been identiﬁed as a
therapist who treats women with issues related to either eating disorders, deliberate self-
harm, or both of these issues. If you feel comfortable assisting with data collection for
this research after reviewing the study materials you have received, please distribute
survey packets to clients who meet study criterion and who you feel will not be
signiﬁcantly, adversely affected by participation.

Some clients may report appreciation for the opportunity to share their experiences, and
clients may beneﬁt from participating in this study through increased self-awareness and
self-understanding. However, there is a risk that study participation may activate affect-
laden memories or induce negative self-evaluative states. Therefore, as an added
precaution to protect your clients, please inform potential participants of your availability
to discuss any adverse reactions or feelings that arise from potential study participation.

The following criterion must be met by potential study participants addressing issues
related to the presence or history of eating disorders and/or deliberate self-harm:

1. Only volunteers are asked to participate in this research.

2. Participants must be female.

3. Participants must be age 18 or older.

4. Participants must be in treatment at the time of study participation.

104

5. Potential participants must not be actively suicidal or psychotic.

Each survey packet contains all of the material necessary for participation in the study.
Each survey packet includes the following material: a Participant Recruitment letter, two
copies of the Informed Consent form, a Demographic Questionnaire, a Help-Seeking and
Treatment History Questionnaire, and a Perfectionism Questionnaire, containing three
perfectionism measures. The Perfectionism Questionnaire contains questions related to
self-oriented perfectionism, other-oriented perfectionism, socially prescribed
perfectionism, intrapersonal perfectionism, interpersonal perfectionism, and self-
presentational perfectionism. It will take approximately 45 minutes to complete the
questionnaires contained within the survey packet.

Once you distribute survey packets to potential participants, potential participants will
have all of the information they need to make a decision regarding participation and to
complete and return study material to the researcher in a conﬁdential manner. Neither
the participants’ names nor your name, as therapist, will appear on any of the completed
questionnaires within the survey packet. Additional safeguards regarding the protection
of conﬁdentiality are outlined in the informed consent form.

If you have questions or concerns about assisting with this study, please contact Anne
Kubal by phone at (630) 854-5168 , or by e-mail at kubalann@msu.edu; or contact Dr.
Nancy Crewe by phone at (517) 432-0606, or by e-mail at ncrewe@msu.edu. If you have
questions or concerns about the rights of study participants, or are dissatisﬁed at anytime
with any aspect of this study, you may contact - anonymously if you wish - Peter
Vasilenko, Ph.D., Chair of the University Committee on Research Involving Human
Subjects (UCRIHS) by phone: (517) 355-2180, fax: (517)432-4503, email:
ucrihs@msu.edu, or regular mail: 202 Olds Hall, East Lansing, MI 48824.

If you would like a copy of the completed study, including the results of the study, please
contact Anne Kubal through the e-mail address listed above or by phone, with the
number listed above.

Again, thank you for your potential assistance and cooperation with this research project.
Additional research is needed to better understand the manner in which perfectionistic
tendencies and perfectionistic self-presentation impacts the lives and treatment of women
struggling with deliberate self-harm and/or eating disorder issues. My goal in conducting
this study is to increase our understanding of these issues.

Sincerely,

Anne E. Kubal
PhD. Candidate in Counseling Psychology
Michigan State University

105

APPENDIX B

Participant Recruitment Form

Volunteers Needed for Research on Perfectionism!
Information and Directions for Potential Participants

My name is Anne Kubal. I am studying to be a psychologist at Michigan State
University. One of my goals as a psychologist-in-training is to work with other
professionals to improve the treatment experiences of women who seek help for eating
disorders and/or self-injury. The purpose of this study is to help counselors and
therapists learn more about the nature and prevalence of perfectionistic tendencies among
women seeking treatment for either or both of these issues.

I am seeking women, age 18 and older, who are willing to share their thoughts, beliefs,
and experiences through study participation. Only volunteers are asked to participate in
this research. Your therapist has been asked to distribute questionnaires to women who
are addressing issues related to eating disorders and/or self-injury, but participation is
completely voluntary and your therapist will not be informed about your decision to
participate or not participate unless you choose to tell your therapist about your decision.

If you choose to participate in this study, all of the information you provide will be held
conﬁdential. Your name will not appear anywhere on the survey; responses will only be
associated with an identiﬁcation number. A detailed description of the precautions that
will be taken to protect your conﬁdentiality is included in the enclosed “Informed
Consent” form.

If you do chose to participate, please read the enclosed “Informed Consent” form
carefully. This form outlines your rights as a participant. You may keep one copy of this
form for your own records. I ask that you return the second copy of this form to me in
the provided self-addressed, stamped envelope. A second self-addressed, stamped
envelope (the large brown envelope this letter is attached to) is provided so that you may
return your completed survey to me without your name being attached to the survey.

Thank you for thinking about participating in this study.
Sincerely,
Anne Kubal

Doctoral Student in Counseling Psychology
Michigan State University

106

APPENDIX C

Informed Consent
Perfectionism Among Women Seeking Help for Eating Disorders and/or Self-Injury

Thank you for your interest in this research project. This project is being conducted by
Anne Kubal, a doctoral candidate in Counseling Psychology at Michigan State
University, under the supervision of Dr. Nancy Crewe, a professor in the Department of
Counseling, Educational Psychology, and Special Education at Michigan State
University.

The purpose of this investigation is to learn more about the nature and prevalence of
perfectionistic tendencies among women who have sought psychological or psychiatric
help for self-injury, eating disorders, or both of these issues. Only volunteers are asked to
participate in this research. Your therapist has been asked to distribute questionnaires to
women who are addressing issues related to eating disorders and/or self-injury, but
participation is completely voluntary and your therapist will not be informed about your
decision to participate or not participate unless you choose to tell your therapist about
your decision.

If you chose to participate, your responses will be completely conﬁdential. The following
precautions will be taken to protect your conﬁdentiality. Neither your name nor your
therapist’s name will appear on any of the questionnaires. Your responses will only be
associated with a subject identiﬁcation number. This informed consent and the list that
matches names with identiﬁcation numbers will be kept separately from all questionnaire
responses in a locked ﬁle cabinet. Questionnaire responses will be kept in a separate
locked ﬁle cabinet. Questionnaire data will be entered into a computer, analyzed, and
stored in a password-protected ﬁle on the researcher’s personal computer. At completion
of the project, data will be transferred to disks, and these disks will be stored in the
locked cabinet together with questionnaire responses. The locked ﬁles cabinets and
computer in which data will be stored are located in a locked room. Only the researchers
conducting this study will have access to any of the study information. Data will be
retained for a minimum of three years in these secure locations and destroyed after 3
years by shredding. At no time will your name be released in association with this study.
No individual results will be reported. Your privacy will be protected to the maximum
extent allowable by law.

If you choose to participate in this study, please complete the packet of self-report
questionnaires provided by your therapist. The questionnaires will ask about your
personal experiences and beliefs, experience with psychological or psychiatric treatment,
and some of the issues you may be dealing with in treatment. You will also be asked to
report possible past experiences, including a history of abuse. The entire process should
take approximately 45 minutes

107

Please read each question carefully and answer as honestly as possible. Although some
people report appreciation for the opportunity to share their experiences, and you may
beneﬁt from participating in this study through increased self-awareness and self-
understanding, there is a risk that you may feel uncomfortable responding to some
questions. For example, some of the questions will ask you to report your thoughts and
feelings, and ask you to report negative experiences you may or may not have had in your
lifetime. You are under no obligation to answer any of the questions. You may refuse to
participate at all, decline to participate in certain portions of the study, or not answer
certain questions. There are no right or wrong answers. At any time during your
participation, you have the right to discontinue your participation without penalty or loss
of beneﬁts to which you are entitled.

If you are distressed while answering some of the questions, or later after you have
completed the questionnaire, you are encouraged to discuss your feelings with your
therapist. If you have questions or concerns about participating in this study, please
contact Anne Kubal by phone at (630) 854-5168 , or by e-mail at kubalann@msu.edu; or
contact Dr. Nancy Crewe by phone at (517) 432-0606, or by e-mail at ncrewe@msu.edu.
If you have questions or concerns about your rights as a study participant, or are
dissatisﬁed at anytime with any aspect of this study, you may contact - anonymously if
you wish - Peter Vasilenko, Ph.D., Chair of the University Committee on Research
Involving Human Subjects (UCRIHS) by phone: (517) 355-2180, fax: (517)432-4503,
email: ucrihsfglmsuedu. or regular mail: 202 Olds Hall, East Lansing, MI 48824. Please
make sure you have all of your questions answered before you sign this consent form. If
you have read the information above and consider yourself to be fully informed about this
research study, please print and sign your name below. Keep the second copy of the
consent form for your records.

 

My signature below indicates that I voluntarily agree to participate in the study as
described above:

 

 

 

PRINT your name here SIGN your name here DATE

 

If you would like the results of this research study, please mark the method by which you
would prefer to receive results and provide either a mailing address below, or an e-mail
address where the results can be sent electronically. Alternatively, you may contact Anne
Kubal by phone at (630) 854-6158 or by e-mail at kubalann@msu.edu to request the
results of this study at a later date.

I would prefer to have the results of this research study sent to me by regular mail at
the following address:

 

 

 

I would prefer to have the results of this study sent to me via e-mail at the following
e-mail address:

 

108

APPENDIX D

Consent F orm for use at Linden Oaks at Edward Hospital

Project: Perfectionism Among Women Seeking Help for Eating Disorders and/or
Self-Injury

Investigator: Nancy Crewe, Ph.D.

Sub-Investigator: Anne Kubal, M. A.

Address: Anne Kubal, M.A.
2868 Valley Forge Rd.
Lisle, IL 60632

24 Hour Contact Number: Anne Kubal at (630) 854-5168 (cell).
INTRODUCTION/ PURPOSE

Thank you for your interest in this research project. This project is being conducted by
Anne Kubal, a doctoral candidate in Counseling Psychology at Michigan State
University, under the supervision of Dr. Nancy Crewe, a professor in the Department of
Counseling, Educational Psychology, and Special Education at Michigan State
University.

The purpose of this investigation is to learn more about the nature and prevalence of
perfectionistic tendencies among women who have sought psychological or psychiatric
help for self-injury, eating disorders, or both of these issues. Only volunteers are asked to
participate in this research. Your therapist has been asked to distribute questionnaires to
women who are addressing issues related to eating disorders and/or self-injury, but
participation is completely voluntary and your therapist will not be informed about your
decision to participate or not participate unless you choose to tell your therapist about
your decision.

About 180 subjects will be asked to participate from Linden Oaks Hospital and from
cooperating private therapists in the Naperville, Illinois area.

PROCEDURES/ CONFIDENTIALITY

If you chose to participate, your responses will be completely conﬁdential. The following
precautions will be taken to protect your conﬁdentiality. Neither your name nor your
therapist’s name will appear on any of the questionnaires. Your responses will only be
associated with a subject identiﬁcation number. This informed consent and the list that

109

matches names with identiﬁcation numbers will be kept separately from all questionnaire
responses in a locked ﬁle cabinet. Questionnaire responses will be kept in a separate
locked ﬁle cabinet. Questionnaire data will be entered into a computer, analyzed, and
stored in a password-protected ﬁle on the researcher’s personal computer. At completion
of the project, data will be transferred to disks, and these disks will be stored in the
locked cabinet together with questionnaire responses. The locked ﬁles cabinets and
computer in which data will be stored are located in a locked room. Only the researchers
conducting this study will have access to any of the study information. Data will be
retained for a minimum of three years in these secure locations and destroyed after 3
years by shredding. At no time will your name be released in association with this study.
No individual results will be reported. Your privacy will be protected to the maximum
extent allowable by law.

If you choose to participate in this study, please complete the packet of self-report
questionnaires provided by your therapist. The questionnaires will ask about your
personal experiences and beliefs, experience with psychological or psychiatric treatment,
and some of the issues you may be dealing with in treatment. You will also be asked to
report possible past experiences, including a history of abuse. The entire process should
take approximately 45 minutes. Please read each question careﬁrlly and answer as
honestly as possible.

RISKS AND BENEFITS OF PARTICIPATION

Although some people report appreciation for the opportunity to share their experiences,
and you may beneﬁt from participating in this study through increased self-awareness
and self-understanding, there is a risk that you may feel uncomfortable responding to
some questions. For example, some of the questions will ask you to report your thoughts
and feelings, and ask you to report negative experiences you may or may not have had in
your lifetime. You are under no obligation to answer any of the questions. You may
refuse to participate at all, decline to participate in certain portions of the study, or not
answer certain questions. There are no right or wrong answers. At any time during your
participation, you have the right to discontinue your participation without penalty or loss
of beneﬁts to which you are entitled.

If you are distressed while answering some of the questions, or later after you have
completed the questionnaire, you are encouraged to discuss your feelings with your
therapist. If you have questions or concerns about participating in this study, please
contact Anne Kubal by phone at (630) 854-5168 , or by e-mail at kubalann@msu.edu; or
contact Dr. Nancy Crewe by phone at (517) 432-0606, or by e-mail at ncrewe@msu.edu.

ALTERNATIVE TREATMENT

You have the ability to choose to IE participate in this research project. If you decline to
participate, it will not impact your current or future treatment plan .

110

AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH

INFORMATION

A new Privacy Rule has been issued under a federal law which requires the investigators
conducting this project to ask for permission from participants to use and share protected
health information for purposes of this project.

The following sections explain how your protected health information will be collected,
used and shared with certain other persons involved in the project and describe your

rights.

1. The protected health information that may be used and disclosed includes:
0 All information collected during the project as described in this Informed
Consent Form; and
0 health information in my medical records that is relevant to the Research

2. Your health providers may disclose information in your medical records:
0 To the researchers; and,
o as required by law, to ethics and/or institutional review boards, and other
persons who are required to watch over the conduct of this research study.

3. The investigators in charge of this project may:
0 Use and share your protected health information among themselves and with
other participating investigators involved in this project
0 Disclose your health information as required by law, to ethics and/or
institutional review boards, such as:
- Edward Hospital Institutional Review Board
' Michigan State University Committee on Research Involving
Human Subjects

4. Please note that:

0 You do not have to consent to this Authorization to use or disclose
protected health information, but if you do not, you will not be allowed to
participate in the Research.

0 You (or your legally authorized representative) may change your mind and
revoke this authorization at any time. To revoke this Authorization to use
or disclose protected health information, you must write to

Anne Kubal, M.A.

2868 Valley Forge Rd.

Lisle, IL 60632
However, if you revoke this Authorization, you will no longer be
allowed to participate in the Research. Also, even if you revoke
this Authorization to use or disclose protected health information,
the information already obtained by the Researchers and the

111

Sponsor of this study may be used and disclosed as permitted by
this Authorization and the Informed Consent.

5. This Authorization does not have an expiration (ending) date.

FINANCIAL INFORMATION

Participation in this project is at no additional cost to you and you will not receive any
payment for your participation.

VOLUNTARY PARTICIPATION AND WITHDRAWAL STATEMENT

Your participation in this project is voluntary. Your decision whether or not to participate
will not interfere with your future care at this institution, or your right to health care or
other services to which you are otherwise entitled. You are not waiving any legal claims
or rights because of your participation in this project. If you do decide to participate, you
are free to withdraw your consent and discontinue participating at any time.

You are encouraged to ask questions regarding your participation in the project. In the
event you experience any problems related to your participation in this project, or you
experience a project-related injury or should have any questions; you should immediately
contact Anne Kubal, M.A., at (630) 854-5168.

If you have additional questions concerning your rights or welfare as a participant, you
should contact the manager of the Institutional Review Board (IRB) at Edward Hospital,
or designated substitute, by telephoning (630) 527-3042 or 527-3010. An Institutional
Review Board is a group of scientiﬁc and non-scientiﬁc individuals who perform the
initial and on-going ethical review of this project with the participant’s safety and welfare
in mind. If you have questions or concerns about your rights as a study participant, or are
dissatisﬁed at anytime with any aspect of this study, you also may contact - anonymously
if you wish - Peter Vasilenko, Ph.D., Chair of the University Committee on Research
Involving Human Subjects (U CRIHS) at Michigan State University by phone: (517) 355-
2180, fax: (517) 432-4503, email: ucrihs@msu.edu, or regular mail: 202 Olds Hall, East
Lansing, MI 48824.

112

CONSENT

Your signature below indicates that you understand the preceding information, that your
questions have been answered to your satisfaction, and that you freely and voluntarily
decided to participate in this project. You understand that refusal to participate will result
in no penalty or loss of medical care to which you are otherwise entitled. You understand
that you will not give up any of your legal rights by signing this form. You will receive a
copy of this consent form for your records.

If you have read the information above and consider yourself to be fully informed about
this research study, please print and sign your name below. Keep the second copy of the
consent form for your records.

 

My signature below indicates that I voluntarily agree to participate in the study as
described above:

 

 

 

PRINT your name her;— SIGN your name here _ _ DATE

 

Name of Investigator Signature Date

If you would like the results of this research study, please mark the method by which you
would prefer to receive results and provide either a mailing address below, or an e-mail
address where the results can be sent electronically. Alternatively, you may contact Anne
Kubal by phone at (630) 854-6158 or by e-mail at kubalann@msu.edu to request the
results of this study at a later date.

I would prefer to have the results of this research study sent to me by regular mail at
the following address:

 

 

 

 

I would prefer to have the results of this study sent to me via e-mail at the
following e-mail address:

 

113

APPENDIX E

Demographic Questionnaire

1. Please circle the number next to your gender.

(1) male
(2) female

2. How old are you? years old
3. Please circle the number next to your race/ethnicity.

(1) Asian, Asian-American
(2) Black, African-American
(3) Hispanic, Latino

(4) Native American

(5) Paciﬁc Islander

(6) White, European American
(7) Multiracial, Mixed Race
(8) Other, please specify:

 

4. Please circle the number next to your marital status.

(1) Single

(2) Married

(3) Separated

(4) Divorced

(5) Widowed

(6) Other, please specify:

 

5. How many children do you have? Please circle.

(1) None

(2) One child

(3) Two children

(4) Three children

(5) Four or more children

6. Which state (i.e. Illinois, Ohio) do you live in?

 

114

7.

10.

Who currently lives in your home with you? Please circle.

(1) I live alone.
(2) I live with a roommate.

(3) I live with my romantic partner or spouse and children.
(4) I live with my children only.

(5) I live with my romantic partner or spouse only.

(6) I live with my parents.

(7) I live with relatives other than my parents

(8) I live in a group home.

(9) Other, please specify:

 

How much education have you completed? Please circle.

(1) less than high school

(2) high school degree (or GED)

(3) post high school (e.g. trade, technical, or secretarial school)
(4) some college (e.g. one year, associate’s degree)

(5) completed college (e.g. bachelor’s degree)

(6) some graduate or post-bachelor’s training

(7) completed graduate degree or post-bachelor’s training

What is your current employment status? Please circle.

(1) full-time work

(2) part-time work

(3) unemployed

(4) disabled

(5) full-time student

(6) part-time student

(7) multiple categories, please specify:

 

If you are employed, what is your occupation?

 

If employed, what is your yearly income? Please circle.

(1) $0-$15,ooo
(2) $15,001-$30,000
(3) 330,001-345,000
(4) $45,001-$60,000
(5) $60,001 -$75,000
(6) Over $75,000

115

APPENDIX F

Help-Seeking and Treatment History Questionnaire

This questionnaire is divided into 4 sections. The questions are designed to obtain
information about your treatment experiences and some of the issues you may be dealing
with in treatment. Please read each question carefully and answer each question as
honestly as possible. ALL OF YOUR RESPONSES WILL BE KEPT CONFIDENTIAL
AND YOUR NAME WILL NOT BE ATTACHED TO ANY OF YOUR ANSWERS. A
space is provided at the end of the questionnaire if you would like to comment on your
experiences ﬁlling out the questionnaires or add any additional information that you
would like to share.

SECTION I

The following section asks you to provide information about your experiences with
psychological and/or psychiatric treatment. One of the primary goals of this study is to
gain information that will help improve women’s experiences with treatment.

1. Are you currently seeking psychological or psychiatric help?

yes no

 

2. If yes, what type of treatment are you receiving?

outpatient therapy

inpatient therapy/ hospitalization

partial hospitalization

support group (please specify: )

3. Approximately how long have you been receiving treatment?

less than one month

between 1 month and 6 months
between 6 months and 1 year
more than 1 year

4. Treatment has helped me .............

not at all
a little

a lot

not sure

116

SECTION II

The following section contains questions about eating disorders. If you do not have an
eating disorder, and have never had an eating disorder, please check “false, " “no, " or
“not applicable” where appropriate.

1. I currently have an eating disorder. true false

If true, my diagnosis is:

(l) anorexia

(2) bulimia

(3) anorexia AND bulimia

(4) eating disorder not otherwise speciﬁed
(5) I am not sure of my diagnosis.

2. I have had an eating disorder in the past. true false

If true, my diagnosis was:

(1) anorexia

(2) bulimia

(3) anorexia AND bulimia

(4) eating disorder not otherwise speciﬁed
(5) I am not sure of my diagnosis.

3. Was an eating disorder one of the primary reasons you sought psychological
or psychiatric help? yes no not applicable

4. Have you discussed your eating disorder with your therapist?

yes no not applicable

5. Have you ever been hospitalized in a psychiatric unit as a result of your eating
disorder? yes no not applicable

 

117

SECTION III
This section asks you to respond to true/false questions about traumatic events you may
have experienced during your lifetime. Definitions of terms are provided.

1. Child neglect is deﬁned as failure by a parent or caretaker to provide for a child’s
basic needs. Neglect may be physical (i. e. failure to provide necessary food or shelter, or
lack of appropriate supervision), medical (i. e. failure to provide necessary medical or
mental health treatment), educational (i. e. failure to educate a child or attend to special
education needs), or emotional (i. e. inattention to a child’s emotional needs, failure to
provide psychological care, or permitting the child to use alcohol or other drugs.

As a child, I remember being neglected.

true false

2. Physical abuse is defined as physical injury (ranging from minor bruises to severe
fractures or death) as a result of punching, beating, kicking, biting, shaking, throwing,
stabbing, choking, hitting (with a hand, stick, strap, or other object), burning, or
otherwise harming a child.

As a child, I remember being physically abused.

true false

3. Sexual abuse includes activities by a parent, caretaker, or other adult such as
fondling a child ’s genitals, penetration, incest, rape, sodomy, indecent exposure, and
exploitation through prostitution or the reproduction of pornographic materials.

As a child, I remember being sexually abused.

true false

4. As an adult, I have been physically abused or assaulted.
true false

5. As an adult, I have been sexually abused or assaulted.

true false

6. Was a history of trauma or abuse one of the primary reasons you sought
psychological or psychiatric help? yes no not applicable

118

SECTION IV

The questions in this section refer to deliberate self-harm or self-injury, sometimes called
self-mutilation. Deliberate self-harm or self-injury is the deliberate destruction or
alteration of one 's own body, performed without meaning to commit suicide. Examples
of self-injury include cutting oneself burning oneself: biting oneself: head-banging,
interfering with the healing of wounds, or scratching until one bleeds. For the purpose of
this study, self-injury or deliberate self-harm DOES NOT include excessive drinking of
alcohol or overdosing on drugs.

1. Have you ever self-injured? yes no

 

"If your answer to the above question is “yes,” please unseal and complete the

remaining pages of this questionnaire.

I""‘If your answer is “no, ” then you have finished the questionnaire. If you would like
to comment about any of the questions asked as part of this research study, provide
feedback about the questions to the researcher, or share what it was like for you to
participate in this study, please do so in the space provided below. Your participation, as
well as any comments you would like to make, is greatly appreciated!

 

 

 

 

 

 

 

 

 

 

119

SECTION IV — Please answer the remaining questions only if you responded “yes ”
to Question # I on the previous page.

2. Please estimate and circle the number of times you have self-injured?

(1) only once

(2) 2 - 5 times

(3) 6 — 10 times

(4) 11 —20 times

(5) 21 —50 times

(6) more than 50 times

3. At what age did you ﬁrst self-injure?

4. List the ways that you have banned yourself. List them in the order in which
you have most often banned yourself.

 

 

 

 

SAPP’E"?

 

5. When did you last harm yourself?

(1) within the last week

(2) within the last month
(3) within the last 6 months
(4) within the last year

(5) more than a year ago

6. Was self-injury one of the primary reasons you sought psychological or
psychiatric help? yes no

7. Have you discussed your self-injury with your therapist? yes no

 

8. Have you ever been hospitalized in a psychiatric unit as a result of your self-
injury? yes no

 

9. Please check the appropriate response to the following statement.

I no longer struggle with self-injury. true false

120

If you would like to comment about any of the questions asked as part of this research
study, provide feedback about the questions to the researcher, or share what it was like
for you to participate in this study, please do so in the space provided below. Your

participation, as well as any comments you would like to make, is greatly appreciated!

 

 

 

 

 

 

 

 

 

 

121

REFERENCES

122

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