Perfectionism in the anorexic adolescent

For the 30 years that I have been evaluating and treating adolescents who suffer from anorexia, I have been struck by their perfectionism - expressed daily and through all of their actions. I can still remember a comment made by one of my supervisors in New York when he was presenting the case history of an anorexic adolescent: "Spotting an anorexic adolescent is easy because invariably she will not have shown any problems in life until the appearance of the anorexia. She will have been a "model child", but in fact we can ask ourselves; is she not a "modelled" child? One can notice at first contact that the anorexic adolescent adapts herself in accordance to the expectations of others; she does her best to do what others ask. Deep down she experiences a constant pressure to please and to succeed. The anorexia therefore becomes a "project", whose success is vital. The adolescent needs the anorexic identity as a refuge from the immense physical and psychological transformations that are part of that phase of development. Their all-pervading perfectionism is not a bluff but rather an intrinsic necessity, a way to negotiate an impasse in their development.

The anorexic adolescent justifies her eating habits with an argument based on health and the necessity to make the right dietary choices for herself and for her family. Her weight loss is always preceded and maintained by a discourse which, at first glance, is both interesting and appealing, and which initially elicits agreement from others. With time, however, the people around them begin to realize that the pretence of pursuing health is precariously balanced because of the small amounts of food actually ingested. Their food choices are perfect, the way they feed themselves is exemplary, but the virtues of their discourse is spoiled by the blatant quantitative deficit; they in fact become trapped by their "dietary" perfectionism. In effect, anyone who tries to interfere with an anorexic adolescent in a restrictive phase faces the difficult task of having to argue every food choice.

Their perfectionism in academic pursuits is impressive in terms of grades obtained and the perfection of the work done. Every June, I evaluate adolescents who have been awarded their school's Governor General's Medal, who have earned many honours, magna cum laude mentions, etc. Their parents, as well as school authorities experience a certain discomfort with respect to the displayed academic excellence. It is as if the awarding of these honours somehow "celebrates" the anorexia of these young adolescents, with those around them having acted as involuntary accomplices. This twist of events leads me to question - among other things - the kind of over-protection that these adolescents benefit from in their school environment. If their act of self-sabotage (anorexia in this case) was to take another form and, for example, evolve into drug addiction or delinquent behaviour, then the adolescent would be expelled from school. Instead, the anorexic adolescent enjoys, in my opinion a privileged and sometimes pathological protection. The visible fragility coupled with the outstanding academic success inspires an attitude of indulgence and tolerance by school authorities, putting these young girls at risk of developing serious long term consequences. I often tell my patients that I could easily have them fail at school if I forced them to take a course where they would be expected to do nothing. They smile and agree with me. School programs are literally tailor-made for anorexic girls and their pathology. It is no wonder that they are able to obtain such high grades.

As far as socialization is concerned, the perfectionism is a little less obvious. These girls do not pose a real problem since they don't go out, they don't really listen to popular music, they don't smoke or take drugs, they don't have go out with boys and their sexuality is "non-existent". The fact that they don't socialize makes them appear even more perfect. One must realize that this lack of socialization is protective; otherwise if they were placed in a social situation they would have to "fake" it. They don't really feel comfortable with the so-called "normal" adolescents, because in fact from a biological and hormonal point of view they are in an immature state. We all know that the socialization period during adolescence is very important and cannot be avoided without running the risk of hindering the ability to establish healthy relationships with others in the future; another way in which perfectionism can be harmful.

For those who are enrolled in specific school programs such as international education, special secondary school courses for athletically-gifted pupils, or double or triple diplomas, their perfectionism is recognized, valued and even considered a prerequisite in the selection process. We tend to forget that these academic choices become golden refuges for the anorexic adolescent. Indeed, their anorexia facilitates their productivity, and most often, once they emerge from the anorexia, they question their choices, often choosing something better suited to who they are and what they want. By investing fully in these kinds of programs, some adolescents get more and more entrenched in their pathology and it may become advisable to pull them out despite their excellent results. Even sadder is the observation that these adolescents do not even derive pleasure from their scholastic investment

I have also come to realize that their perfectionism also expresses itself in their behaviour in therapy. They are always willing to please their therapist, they are very compliant during their appointments (unlike most adolescents of their age), and they appear to do what the therapist want- all this without letting go of their illness. Therapists should be aware that cure must be achieved for the patient's own sake and not to please the therapist: a subtlety that is often difficult to enforce in practice.

Perfectionism in the anorexic adolescent is an integral part of the illness and therefore also part of the suffering. This perfectionism is sometimes enticing and tempting to imitate. However, when further examining what motivates these young adolescents, one realizes that the constant search for perfection is not pleasurable, but a continuous suffering expressed by a triumphant smile that conceals an unsettling anguish. In her book "Pour en finir avec l'excellence", Hélène Pedneault defines excellence as a damned trio: potion, poison and prison. Perfectionism in the anorexic adolescent acts like a magic potion that helps to fill the inner void and thus allows her to "be"; this in turn poisons her existence and imprisons her. As a result, she can not afford to give up the constant search for perfection. It is therefore not surprising to recognize that it will take the adolescent time to rid herself of her pursuit of perfection, to learn to know herself, to be more fulfilled and to become who she really is. It may take months, even years for this gradual transformation to occur.

Jean Wilkins, md
Professeur titulaire de pédiatrie
Responsable, Clinique des troubles de la conduite alimentaire
Section de Médecine de l'Adolescence, CHUME, Hôpital Sainte-Justine