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1d

NTERNATIONAL ARTICLE

erfectionism Dimensions in Children anddolescents with Anorexia Nervosa

OSEFINA CASTRO, M.D., ARACELI GILA, Ph.D., PILAR GUAL, M.D.,

RANCISCA LAHORTIGA, Ph.D., BEGONA SAURA, Ph.D., AND JOSEP TORO, M.D.

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Purpose: To assess the dimensions of perfectionism indolescents with anorexia nervosa in comparison withdolescents from the general population and to validatehe Spanish versions of two measures of perfectionism.

Methods: The Child and Adolescents Perfectionismcale (CAPS), the Perfectionistic Self-Presentation Scale

PSPS) scale, the Eating Attitudes Test (EAT), and theeck Depression Inventory (BDI) were administered to aroup of 71 anorexia nervosa patients (mean age 15.3ears). Moreover, the CAPS and the PSPS were alsodministered to 113 adolescents from the general popu-ation (mean age 14.6 years). The CAPS and the PSPSere administered again after 1 week in 68 subjects to

valuate test-retest reliability.Results: Both the CAPS and the PSPS demonstrated

ood internal consistency (Cronbach alpha for anorexiaervosa patients � .91; Cronbach alpha for general pop-lation � .85) and the two scales of the CAPS also hadlpha coefficients in excess of .7. One-week test-retesteliability was also adequate (r � .80). Anorexia nervosaatients had higher mean scores in Self-oriented perfec-

ionism (p < .001) and Perfectionistic self-presentation (p.001) but not in Socially prescribed perfectionism (p �

292). There were significant correlations among perfec-ionism and the EAT and the BDI. A percentage ofnorexia nervosa patients between 39% and 42% ob-ained a score higher than the mean in the comparison

From the Department of Child and Adolescent Psychiatry andsychology, Institute of Psychiatry and Psychology, IDIBAPS (Institut’Investigacions Biomediques August Pi Sunyer), Hospital Clınic Uni-ersitari of Barcelona, Spain, Barcelona, Spain (J.C., A.G., B.S., J.T.);nternational University of Catalonia, Catalonia, Spain (P.G.); andepartment of Psychiatry and Medical Psychology Clinic, University ofavarre, Pamplona, Spain (F.L.).

Address correspondence to: Dr. Josefina Castro, Department of Childnd Adolescent Psychiatry and Psychology, Institute of Psychiatry andsychology, Hospital Clınic, Universitari, Sabino de Arana 1, Barcelona

p8028, Spain. E-mail: jcastro@clinic.ub.es

Manuscript accepted November 25, 2003.

054-139X/04/$–see front matteroi:10.1016/j.jadohealth.2003.11.094

roup plus two standard deviations in Self-orientederfectionism and Perfectionistics self-presentation.Conclusions: The Spanish version of the CAPS and the

SPS showed good psychometric properties. A percent-ge of 40% of adolescent patients with anorexia nervosahow high Self-oriented perfectionism and Perfectionis-ic self-presentation. © Society for Adolescent Medicine,004

EY WORDS:elf-oriented perfectionismocial prescribed perfectionismerfectionistic self-presentationdolescentsnorexia nervosa

erfectionism is a complex construct characterizedy the setting of and striving for unrealistic personaltandards, a tendency toward critical self-evaluationf these standards are not reached, excessive concernver mistakes, doubts about the quality of personalchievements, and excessive emphasis on precisionnd organization [1]. Excessive perfectionism leadso dissatisfaction with oneself and with others. Au-hors have identified various components withinerfectionism [2–4]. Specifically, Hewitt and Flettescribed self-oriented perfectionism (critical self-crutiny and unrealistic self-imposed personal stan-ards), other-oriented perfectionism (the expectation

hat others should achieve unrealistic standards,endency toward dominance and authoritarianism),nd socially prescribed perfectionism (the need tochieve standards and goals indicated by others)4,5]. These authors have also detected another com-

onent of perfectionism related to self-presentation

© Society for Adolescent Medicine, 2004Published by Elsevier Inc., 360 Park Avenue South, New York, NY 10010

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o others, characterized by great efforts to achieve anmage in front of others without defects or weak-esses in relationship to performance, competence,nd physical appearance. The Perfectionistic Self-resentation Scale (PSPS) was created to evaluate

his kind of perfectionism. This scale has been relatedo eating disorder symptoms, body image avoidance,nd self-esteem [6]. To explore perfectionism in all itsomponents in adult subjects, two different scalesave been produced, both called the Multidimen-ional Perfectionism Scale (MPS) [2,3]. To exploreerfectionism in children and adolescents, Flett andewitt developed the Child and Adolescent Perfec-

ionism Scale (CAPS), which has also been used byther authors in studies of depressive cognitions anderfectionism at these ages [7].

Certain effects of perfectionism have been de-cribed as maladaptive, and this personality charac-eristic is considered a predisposing factor for de-ressive cognitions and hopelessness in bothhildren and adults [5,7,8–11], suicide ideation [12],eadache [13], or chronic insomnia [14].

Anorexia nervosa patients have been found toave greater self-control, inhibition of emotionality,nd conscientiousness [15]. They have also beenescribed as low novelty-seeking and self-directed,nd as presenting high harm avoidance and persis-ence [16]. Bastiani et al reported a higher score onerfectionism, especially self-oriented perfectionism,

n 19 anorexia nervosa patients with a mean age of 24ears [17]. The same group found that patients withbsessive-compulsive disorder and anorexia nervosaad similar scores on the Yale-Brown Obsessiveompulsive Scale, but anorexia nervosa patients’

ymptoms were more closely related to symmetrynd order [18]. Cassidy et al found high obsessionalcores in adolescent anorexia nervosa patients anduggested that this was probably owing to theircores on perfectionism [19]. Other authors havehown that adult patients recovered from anorexiaervosa have higher rates than comparison groupsn a range of scales of perfectionism [20,21]. Perfec-ionism has been proposed as a risk factor for an-rexia nervosa [22,23] and also, high levels of perfec-ionism and weight and shape concerns have alsoeen found in parents of eating disorder patients24].

Other authors have shown an association betweenertain dimensions of perfectionism and abnormalating attitudes, and between perfectionism and ex-essive commitment to exercise and dietary restraintn college students from the general population

6,25]. In a sample of adolescent girls from the p

eneral population, Martin et al demonstrated thatieters scored higher in self-presentational concern

han nondieters [26]. Only socially prescribed perfec-ionism has been related to binge eating [27]. Thereat majority of these studies of perfectionism andnorexia nervosa have been carried out with adultatients, and none has specifically studied adoles-ents. Perfectionistic self-presentation is an aspecthat may be crucial for anorexia nervosa at theseges, as external appearance is very important forelf-esteem, and a high perfectionism can drive pa-ients to pursue a perfect body.

The study aimed to validate the Spanish versionsf the CAPS and the PSPS in a population of adoles-ents and to evaluate different aspects of perfection-sm in a sample of adolescent anorexia nervosaatients.

ethodsubjects and Procedure

he group of subjects from the general populationomprised 113 female adolescents from primary andecondary schools in Barcelona. The ages rangedrom 11 to 19 years (mean � 14.6; SD � 2.1).ermission was obtained from school authorities andarents to carry out the study. Subjects were told that

he purpose of the study was to evaluate perfection-stic tendencies in normal children and adolescents,nd they accepted to collaborate voluntarily and tonswer the questionnaires anonymously .The scalesere administered at school during a normal classay and took about a half an hour to complete.

The group of patients comprised 71 female ado-escents aged 11 to 19 years (mean � 15.3; SD � 1.7)

ho fulfilled DSM-IV diagnostic criteria [28] fornorexia nervosa at the moment of starting treatmentt the Eating Disorders Unit of the Child and Ado-escent Psychiatry and Psychology Department ofhe Hospital Clinic Universitari in Barcelona. Pa-ients treated at the unit were asked to collaborate inhis study, and were informed that their responses

ere confidential. Study procedures were approvedy the Ethics Committee of the Institution. Patientsere at different periods of their treatment pro-

rams; some were inpatients, others were attendinghe Day Hospital, and others were outpatients. Thistrategy ensured that the sample presented a wideange of BMIs and treatments, but they may not haveet diagnostic criteria at the time they completed the

ssessment.Treatment in this unit is based on a multidisci-

linary approach combining biological management,

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394 CASTRO ET AL JOURNAL OF ADOLESCENT HEALTH Vol. 35, No. 5

utritional rehabilitation, a behavioral programimed to improve eating patterns and weight, indi-idual and group cognitive treatment, and individ-al and group parent counseling. Only patients withood compliance with treatment are attended asutpatients. If weight and eating behavior do not

mprove, patients are hospitalized or required tottend the Day Hospital. When physical risk is high,sychopathology intense, or collaboration in the out-atient setting very poor, inpatient treatment is in-icated.

easures

he Child and Adolescent Perfectionism ScaleCAPS) is a self-report questionnaire of 22 itemsased on a multidimensional conceptualization oferfectionism [7]. It has two scales: “Self-orientederfectionism” with 12 items (e.g., “I try to be perfect

n every thing I do,” “I always try for the top score ontest”. . .) and the other “Socially prescribed perfec-

ionism” with 10 items (e.g., “There are people in myife who expect me to be perfect,” “People expect

ore from me than I am able to give”. . .).The Perfectionistic Self-Presentation Scale (PSPS)

6,29] scale is a self-report questionnaire of 27 itemsbout the subject’s need to appear perfect to othersnd not to show defects or difficulties (e.g., “I will dolmost anything to cover up a mistake,” “I mustlways appear to be perfect.”..). These two scales oferfectionism were translated into Spanish by arocess of translation and back translation carriedut by two Spanish experts and one with English asative language.

The Eating Attitudes Test (EAT) [30,31] is a self-eport questionnaire of 40 items on abnormal eatingehaviors and attitudes.

The Beck Depression Inventory (BDI) [32,33] is aelf-report questionnaire of 21 items to evaluateepressive symptomatology.

tatistical Analysis

he internal consistency of the questionnaire wasetermined with Cronbach alpha coefficient, whichas to be higher than 0.7. Test-retest reliability wasnalyzed by the Pearson product moment correlationetween the scores obtained by the subjects at twovaluations with a 1-week interval and by the Stu-ent’s t-test for paired samples to compare the meanbtained in the questionnaire at these two moments.

he Student’s t-test for independent samples was m

sed to compare the means obtained by differentroups of patients. The �2 test was used to comparehe percentages of patients and adolescents from theomparison group with a high score on the scales.he Pearson product moment correlation was alsosed to study the association between the question-aires. The level of statistical significance was p �

05. Statistical analysis was performed using the SPSSackage [34].

esultsnternal Consistency of the CAPS and theSPS Questionnaires

able 1 shows the internal consistency of the perfec-ionism questionnaires measured by the Cronbachlpha coefficient. Alpha coefficients for the CAPS, itswo scales, and the PSPS were all higher than .75 innorexia nervosa patients, in adolescents from theeneral population, and in all subjects taken to-ether. All alpha coefficients were higher for an-rexia nervosa patients (in excess of .9) than forubjects from the general population.

est-retest Reliability of the CAPS and theSPS Questionnaires

he test-retest reliability with a 1-week interval in 68dolescents (35 from the general population and 33norexia nervosa patients) was .83 for both scales. Inhe comparison between the mean obtained in theuestionnaires at first administration and the secondfter a 1-week interval, there were no statisticallyignificant differences, either for the CAPS (firstdministration: mean � 66.5; SD � 14.5, and second:

able 1. Internal Consistency of the Perfectionismuestionnaires in Anorexia Nervosa Patients and

ubjects from General Population

Internal Consistency(Cronbach alpha)

AnorexiaNervosa

NormalSubjects

GlobalSample

APS .91 .85 .89elf-oriented perfectionism scale .92 .75 .88ocially prescribed perfectionismscale

.92 .82 .87

SPS .95 .85 .93

CAPS � Child and Adolescent Perfectionism Questionnaire;SPS � Perfectionistic Self Presentation Scale.

ean � 66.6; SD � 16.3; t � .15; p � .880) or the PSPS

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first administration: mean � 112.1; SD � 31.7, andecond: mean � 115.4; SD � 33.6; t � 1.44; p � .154).

ifferences Between Anorexia Nervosa Patientsnd Comparison Group

igure 1 shows the mean scores obtained by patientsnd subjects from the general population on theerfectionism questionnaires. There were statisti-ally significant differences between the mean scorebtained on the Self-oriented scale of the CAPS (t �.5; p � .001) and in the PSPS (t � 8.2; p � .001) inoth groups. In contrast, on the Socially prescribederfectionism scale of the CAPS, there were notatistically significant differences between anorexiaervosa patients and normal subjects (t � 1.01; p �

292).

ercentage of Subjects with High Scores on Self-riented Perfectionism and Perfectionistic Self-resentation

he percentages of subjects with high scores on thewo components of perfectionism that differentiatenorexia nervosa patients from the comparisonroup were determined. A high score was consid-red when a subject obtained a score higher than theean of the comparison group plus two standard

eviations. In Figure 2, these percentages of both

igure 1. Differences (Student Fisher’s t-test; two-tailed) betweennorexia nervosa patients (n � 71) and comparison group (n � 113) inhe mean score obtained in the Socially prescribed perfectionism andelf-oriented perfectionism scales of the CAPS and in the PSPS. CAPS

Child and Adolescent Perfectionistic Scale; PSPS � Perfectionisticelf-Presentation Scale.

roups of subjects are shown for the subscale ofPT

elf-oriented perfectionism of the CAPS and theerfectionistic Self-presentation Scale. The percent-ges of anorexia nervosa patients with a high scoren both scales were significantly higher than theercentages of the comparison group.

orrelations Among Age, Perfectionism, Eatingttitudes, and Depressive Symptomatology innorexia Nervosa Patients

able 2 shows the correlations between the twocales of the CAPS and the PSPS, and also betweenhese two questionnaires and age and the abnormalating attitudes and depressive symptomatologyuestionnaires, the EAT and the BDI. The correlationf the PSPS with the Self-prescribed perfectionism

igure 2. Comparison (�2 test) of the percentages of subjects from bothroups (anorexia nervosa patients, n � 71 and comparison group, n �13) with a score on Self-oriented perfectionism and Perfectionisticelf-presentation above the mean obtained by the comparison group pluswo standard deviations.

able 2. Correlation Coefficient (Pearson r, Two-tailed)etween Age, Self-oriented Perfectionism, Sociallyrescribed Perfectionism, Perfectionistic Self-presentation,ating Attitudes and Depression Questionnaires innorexia Nervosa Patients (N � 71)

PSPS EAT BDI AGE

elf-oriented perfectionism (CAPS) .76*** .32** .37** .07ocially prescribed perfec. (CAPS) .39*** .24* .34*** .06SPS .38** .44*** .04AT .55*** .09DI .09

* p � .05; ** p � .01; *** p � .001.CAPS � Children and Adolescent Perfectionistic Scale; PSPS �

erfectionistic Self Presentation Scale; EAT � Eating Attitudesest; BDI � Beck Depression Inventory.

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396 CASTRO ET AL JOURNAL OF ADOLESCENT HEALTH Vol. 35, No. 5

as higher than with the Socially prescribed perfec-ionism. Correlations of the PSPS and the Self-ori-nted perfectionism with the EAT were higher thanith the Socially prescribed perfectionism. The cor-

elations of the BDI with both scales of the CAPS andhe PSPS were quite similar and statistically signifi-ant. Correlations among all four questionnaires andge were not significant.

iscussionhe results support the psychometric properties of

he Spanish versions of the CAPS and the PSPS andorroborate the usefulness of these scales with ado-escent anorexia nervosa patients. These findingsxtend previous research using these questionnairesith normal populations [6] and with other psychi-

tric adolescent samples [7,12]. In the present study,he internal consistency of the CAPS, its two scales,nd the PSPS was highly acceptable, especially innorexia nervosa patients. The test-retest reliabilityas also adequate in the group that was reexamined

fter 1 week. In addition, the significant, positiveorrelation between the two perfectionism question-aires provides support for their concurrent validity.

Anorexia nervosa patients had significantlyigher mean scores on the Self-oriented perfection-

sm scale of the CAPS than adolescents from theeneral population. In contrast, there was no differ-nce in the means obtained by the two groups in theocially prescribed scale of the CAPS. The meanbtained in the Socially prescribed perfectionism bynorexia nervosa patients and normal adolescentsas lower than the mean obtained in this subscale bygroup of suicide attempters, also adolescents [7].

urthermore, the EAT presented a higher correlationith Self-oriented perfectionism than with Sociallyrescribed perfectionism. These results stress the

mportance of self-oriented perfectionism in anorexiaervosa.

Perfectionism and rigid and obsessive behaviorave been proposed as the reasons for the effective-ess of selective serotonin reuptake inhibitors afterefeeding in helping to maintain weight, preventelapse, and improve rigidity and obsessive behavior35,36]. Other studies in females from the generalopulation have found that abnormal eating atti-

udes are associated with self-oriented perfectionism6]. In 19 anorexia nervosa patients, Bastiani et al [17]ound that the greatest difference with respect toontrol subjects was also in self-oriented perfection-sm and not socially prescribed perfectionism. Ours

s the first study to find a greater self-oriented r

erfectionism in young adolescents with anorexiaervosa. It seems that unrealistic standards for phys-

cal attractiveness and thinness are associated tonrealistic standards for other personal characteris-

ics with high self-imposed goals and critical self-crutiny. Self-oriented perfectionism and Perfection-stic Self-presentation also presented significantifferences between anorexia nervosa patients andontrol subjects. A percentage of about 40% of an-rexia nervosa patients have a very high score onhese two aspects of perfectionism. It shows that inhis subgroup of patients it would be necessary toddress specifically these psychological characteris-ics to achieve a good outcome.

Correlations between the PSPS and the EAT weregain high, showing the importance in these patientsf this aspect of perfectionism, a desire to achieve an

mage in front of others without defects or weak-esses in relationship to performance, competence,nd physical appearance. Physical appearance islosely related to the core symptoms of anorexiaervosa [37,38]. Self-presentation concerns are ofreat importance in adolescence and they have beenelated to unhealthy practices such as dieting [26].ewitt et al also found a statistically significant

orrelation between the PSPS and the EAT in youngemales from the general population, and suggestedhat eating disorders are related to a strong need toresent an image of perfection to others [6]. Allspects of perfectionism correlated with the BDI,specially perfectionistic self-presentation, showinghe relationship between perfectionism and depres-ive symptomatology that other authors haveointed out in adult samples [4,8,9,11] and in ado-

escents [7,12].

tudy Limitations

he first limitation of the study is to use a self-reportuestionnaire as measure of perfectionism. A struc-ured interview would be a better instrument tovoid the subjective perception of the subject innswering the self-report questionnaire, but it woulde also more time consuming for the clinician. Thether limitation is the cross-sectional nature of thetudy. It is not possible to deduce any conclusionbout the importance of high perfectionism in theutcome of the disorder.

onclusions

he present study extends our knowledge about the

elationship between perfectionism and anorexia

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ervosa to young adolescent patients, placing specialmportance on self-oriented perfectionism and per-ectionistic self-presentation. These data support thesychometric properties of the Spanish version of theAPS and the PSPS, in terms of internal consistency,

est-retest reliability, and concurrent validity. Asuch, it is likely to be a useful instrument in clinicalnd research work on anorexia nervosa in Spanish-peaking populations and in young adolescent sam-les. These results show the existence of a bigubgroup (about 40%) of anorexia nervosa patientsith a very high level of perfectionism, especially the

omponents mentioned. In this subgroup it would beecessary to complement the general treatment ofnorexia nervosa with a very specific therapy forerfectionism. Further studies will be necessary tonalyze if this kind of therapy influences definitivelyreatment outcome in this subgroup of anorexiaervosa patients.

his study was supported by a grant from the Marato TV3oundation (expedient 010731).

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