Anorexia nervosa (AN) is highly comorbid with other clinically significant pathologies and extremely prevalent among the general population. Stigmas associated with AN, such as vanity or self-responsibility attributions, may prevent a someone from receiving help. Instead, they may reach out for symptoms unrelated to disordered eating, such as co-occurring depression.  Despite this, folks with AN also reflected positively on their behavior, indicating high remarks of admiration and imitation. This perpetuates the social construct that when weight loss or restriction of caloric intake, is intentional, it is a symbol of achieving a goal and hard work. But there is a threshold to which the weight loss is revered. If it is considered “too extreme” and the case of AN is “more serious”, it may be seen as attention seeking. It has been documented that people with higher severity of AN would be approached with anger rather than compassion to receive help and change their maladaptive behaviors, which in turn, only lessens the chance of the individual of getting help (Geerling & Saunders, 2014).

Within the realm of eating disorder culture, there are websites dubbed “pro-ANA”, short for “pro anorexia”. Researchers have aimed to assess the internalization of pro-ANA website content, general media content, how much influence friends have on one’s view of pro-ANA websites, and peer influence (Juarez et al., 2012). Conclusions regarded the societal “drive for thinness” as a contributing factor to the manifestation of restrictive pathology. There is a positive correlation between the internalization of the content on pro-ANA websites and drive for thinness in women. Consequently, it has been observed that individuals with anorexia become obsessed with the idea of being thin (Ghandour et al., 2018).

Given the rigid nature typically associated with AN, obsessive compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD) are common within the community. Comorbid obsessive-compulsive pathology was associated with a negative outcome when someone has OCD/OCPD/perfectionism while getting treatment for their AN (Crane et al., 2007).

Moreover, there is a defined relationship between perfectionism and anorexia nervosa (Ghandour et al., 2018). These perfectionistic tendencies can be seen even in early childhood and can later influence the development of AN. Perfectionism is multidimensional and can be defined as the desire of extreme, unattainable, unrealistic, standards (Halmi et al., 2012). Oddly enough, levels of perfectionism have been observed to stay the same during recovery while psychiatric and eating disorder behaviors decreased. The greater level of perfectionism, the greater risk for long-term illness (Nilsson et al., 2008). Those with short-term illness showed lower levels of perfectionism after a long period of time. When perfectionism is entangled with the AN, treatment outcomes are impacted.

It has been established that perfectionistic tendencies continue even after recovery is found in long-term AN patients (Forbush et al., 2007).  One study explored the correlation of self-oriented perfectionism in eating disorders, specifically. The researchers administered similar scales to their participants such as the Eating Disorder Inventory (EDI-2; Castro-Fornieles et al., 2007).  Folks with AN scored high on the self-oriented aspect of perfectionism (Castro-Fornieles et al., 2007). Of those with an eating disorder, about 18% of the group scored two standard deviations higher than the mean for self-oriented perfectionism (internal pressure to be perfect). The number of participants who scored higher than the mean in the healthy control group or the adaptive disorder group was significantly lower than those suffering with an eating disorder. As for socially- prescribed perfectionism (external pressure for be perfect), the results were similar for all three groups. As a result, the researchers claimed that self-oriented perfection, opposed to other types of perfectionism, is specifically correlated with an eating disorder than someone with depression or adaptive disorders (Castro-Fornieles et al., 2007).

Fear is a common feeling among sufferers of AN. Pro-ANA websites thrive off the ability to instill fear in its readers, whether it is fear of gaining weight or fear of never being loved. There is a neurological connection between fear and anorexia. It has been known that fear is involved with the amygdala and the hippocampus (Stober, 2003). Stober (2003) hypothesized that there are similarities between phobic anxiety and the fear of being fat, suggesting that pathology of AN is similar to a specific phobia. According to Stober (2003), when these personality traits combine with the hereditary component, it expedites the fear process. They also proposed anorexia lasting for long periods of time due to fear-based learning being expressed through cognitive processes. Stober (2003) notes that weight-related fear is also related to inconsistencies in the limbic system.

In sum, folks with eating disorder pathology, both past and present, are more likely to have a rigid and obsessive mindset, commonly seen with perfectionistic tendencies. Those with anorexia may have a fear of letting go of control, of themselves, and their environment. Given the high prevalence of perfectionistic behaviors, clinicians need to be conscious of this as it relates to their eating disorder symptoms, especially as perfectionistic tendencies may linger after one no longer fits diagnostic criteria for an eating disorder.

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