I remember cutting baby carrots into 6 pieces. Rushing home to eat because I wasn’t “allowed” to eat after 7 pm. Eating the exact portion size–no more, no less. (Oh the rules. I don’t miss them.) Rigid food rules are very common among eating disorder sufferers. These rules can be about anything: the foods you are allowed to eat, how you are allowed to eat them, the time you are allowed to eat them, and so on.
But where do they come from? Why do some individuals have more rules and more ritualistic behaviours than others?
It is a complex question, but a recent study suggests that perfectionism might play a role. Specifically, the authors explored the idea that perfectionism mediates adherence to food rules in disordered eating behaviours. In order words, food rules might be a way in which perfectionism “expresses itself” in eating disorders.
Perfectionism has been identified as both a risk factor and a maintaining variable for disordered eating symptoms. In a prospective study, individuals with severe anorexia nervosa who scored highly on perfectionism at pretest had poorer prognoses, as indicated by assessments 5–10 years later (Bizeul, Sadowsky, & Rigaud, 2001). [...] [I]ndividuals with eating disorders appear to hold themselves to exceptionally high personal standards but may be less concerned about living up to socially prescribed ideals.
In Fairburn and colleagues’ influential transdiagnostic cognitive–behavioral theory of the development and maintenance of eating disorders (Fairburn, Cooper, & Shafran, 2003), over-evaluation of eating, weight, and shape interacts with perfectionistic standards for achievement and self-control to drive the development and maintenance of eating disorder symptoms.
Previous studies have shown that self-imposed food rules may lead to even more preoccupation with food, “setting the stage for more rigid adherence to these rules” and “increasing the likelihood of binge eating” when the temptation is too strong. This might set up a positive feedback loop, whereby rules lead to dietary restraint, which leads to bingeing (or at least, rule breaking), which might lead to more rigid rules and increased preoccupation with forbidden foods and more chances of rule-breaking and “splurging.”
To test the idea that perfectionism mediates food rules in disordered eating, Amanda Brown and colleagues at Emory University recruited 48 female undergraduate students and had them complete a battery of questionnaires about eating behaviours, intuitive eating, body dissatisfaction, self-esteem, perfectionism, and food rules.
To assess adherence to food rules, the authors developed their own 14-item questionnaire that included items: “I eat what I believe to be the right portion size, even when it is not satisfying”, “I feel disappointed in myself when I “spurge” on food I typically do not ea or avoid.”, “I feel the need to follow food rules or diet plans that dictate what, when, and/or how much to eat.”
The participants were between 18-35 (average age: 19) and were racially diverse (67% Caucasian, 19% Asian, 8% Black or African-American, 10% Hispanic or Latino, and 6% Mixed Race or Other).
After all the questionnaire’s were completed, Brown and colleagues analysed the data and found that adherence to food rules was significantly related to self-oriented perfectionism, but NOT other-oriented or socially-oriented perfectionism.
Perfectionism comes in three flavours: self-oriented, other-oriented, and socially-oriented. Self-oriented perfectionism “involves critical self-scrutiny and holding unrealistic, self-imposed personal standards.” Other-oriented and socially-oriented perfectionism is “based on the need to achieve high standards imposed by other people or by society at large.”
Previous studies have shown that individuals with eating disorders appear to hold themselves to very high standards but are less concerned with living up to the standards of others or of society.
Brown and colleagues:
These data support the notion that disordered eating attitudes and behaviors may be largely driven by individuals’ self-imposed high standards. High levels of self-oriented perfectionism may lead individuals to rigidly interpret guidelines for healthy eating and to adhere strictly to these guidelines. Once established, rigid food rules likely become more restrictive and prohibitive, leading to greater preoccupation with food and eating, less intuitive eating, and increased symptoms of disordered eating. While the current data do not address the developmental trajectory of perfectionism, food rules, and disordered eating, they support the hypothesis that adherence to food rules may be a key mechanism by which self-oriented perfectionism leads to eating pathology.
Brown et al suggest that when it comes to treatment, interventions aimed at challenging the patients’ rules (such as exposure to rule breaking without having the option to restrict or purge) may lessen the rigidity of the patients’ beliefs (for example, that eating X will lead to weight gain). This seems to be something that is done routinely, no?
While I think that’s important, I think it is also important for patients to develop an understanding of why they feel the need to enact rigid food rules and what are the positive psychological aspects of following those rules. I think having a deeper understanding of that (as opposed to just focusing on reducing the behaviours) would benefit the patients in the long-run. What are the positive & beneficial aspects of food rules that perpetuate the disorder, and how can they be replaced or ameliorated?
Keep in mind that this was a small study in a private university that enrolled non-clinical participants. It remains to be seen whether these findings are representative of the clinical population. Moreover, the study used a newly developed and not-yet well verified assessment of adherence to food rules. Finally, I’ve done lots of questionnaires, including some of the ones utilized in this study, and um, let’s just say it is a pretty rough measure of things, as far as I’m concerned. Our memories are not stable or accurate, and it is difficult to switch from thinking “in the last week” to “in the last three months” to “in the last 3 weeks,” as many of these questionnaires do.
Despite the limitations, this study provides some preliminary evidence that adherence to food rules might be one way through which perfectionistic traits (particularly self-oriented perfectionism) leads to the development and maintenance of eating disorder behaviours.