Flawless beyond reach and reason : Aspects of Perfectionism in Eating Disorders

Eating disorders (EDs) are common and serious psychiatric disorders causing significant physical and psychological suffering, for both those afflicted and their significant others. Although there has been considerable research on EDs throughout the years, there is still much left to be desired for successful treatment.Perfectionism has been suggested to play a crucial role in the development and maintenance of EDs. Perfectionism has also been suggested to interfere with treatment, and to predict treatment outcome. This thesis aims to illuminate aspects of perfectionism in patients with eating disorders.In Study I the relationship between perfectionism and Sense of Coherence (SOC) in a sample of patients with EDs was investigated. A high extent of perfectionism was significantly correlated to a weak SOC. Socially Prescribed Perfectionism (SPP) was correlated to all SOC components, while Self-Oriented Perfectionism (SOP) was solely correlated to the Manageability component. The results suggested that SOP might be a more healthy aspect of perfectionism compared to SPP. Also, SPP could be more strongly related to psychiatric co-morbidity.In Study II it was explored whether there were different patterns for the extent of SPP and SOP, perseverance/changeability of perfectionism, and how such patterns were related to long-term outcomes. Study data from a large, clinical, and national database was used. Five clusters were found. Persistent SOP was more strongly related to ED symptoms and psychiatric symptoms at baseline compared to other perfectionism patterns. There were no significant differences in outcomes between clusters three years after the initial measure. Patterns of relationships between the extent and possible changes of perfectionism measured with the Perfectionism Scale in the Eating Disorder Inventory (EDI-P) at baseline, and after six months, did not appear to be associated with long-term outcomes in psychiatric health ratings.In Study III semi-structured interviews with 15 patients were conducted and analysed. The narratives were compared with scorings on the EDI-P. No differences were found in the narratives related to EDI perfectionism scores or ED diagnoses. Seven themes were found: The origins of perfectionism, Top performance, Order and self-control, A perfect body, Looking good in the eyes of others, A double-edged coping strategy, and A Sisyphean task. The women in this study did not emphasize their weights or bodies as the main goal of their perfectionistic strivings. Core descriptions were order, self-control, and top performances. All participants described their awareness of the impossibility of reaching perfectionism. Scorings of SOP were significantly higher compared to SPP. The results showed that psychometric measures do not always capture patient definitions of perfectionism, but considering that perfectionism serves as a means to, among other things, regulate affects, and may lead to an exacerbation of an eating disorder, and the development of obsessive-compulsive symptoms, it is important to investigate the definitions of perfectionism. All studies in the present thesis were clinical, naturalistic, and, thus, transdiagnostic. The results showed that perfectionism in patients with EDs is a complex construct, suggesting that perfectionism should be regarded as a compensatory strategy with affect-regulating functions, in line with ED symptoms

A sisyphean task : experiences of perfectionism in patients with eating disorders

Background: Despite the theoretical links between eating disorders and perfectionism, the definition of perfectionismin practice is complicated. The present study explored descriptions and experiences of perfectionism described by atransdiagnostic sample of patients. Methods: In-depth, semi-structured interviews were carried out with 15 patients. The interviews were analyzed byThematic Analysis. A comparison between the patients’ scorings on the Eating Disorder Inventory-Perfectionism scalewas also performed. Results: Seven themes were found: The origins of perfectionism, Top performance, Order and self-control, A perfectbody, Looking good in the eyes of others, A double-edged coping strategy, and A Sisyphean task. The women inthis study did not emphasize weight and body as the main perfectionistic strivings. Core descriptions were instead order,self-control and top performances. All of the participants described the awareness of reaching perfectionismas impossible. Scorings of self-oriented perfectionism was significantly higher compared to socially prescribedperfectionism. No differences in the narratives related to perfectionism scores or eating disorder diagnoseswere found. Conclusions: The results showed that psychometric measures do not always capture the patients’ definitionsof perfectionism, but regarding that perfectionism serves as a means to regulate affects and may lead into anexacerbation of the eating disorder, and the development of obsessive-compulsive symptoms, it is importantto investigate the personal definitions of perfectionism

Perfectionism and sense of coherence among patients with eating disorders

Background: There is a substantial body of research on eating disorders and perfectionism. Also there are several studies on eating disorders and sense of coherence (SOC), but studies regarding all three subjects are sparse. Perfectionism and the degree of SOC are considered central and aggravating aspects of psychiatric conditions, not least in relation to eating disorders. Aims: The present study aimed to describe the relationship between perfectionism as operationalized by Garner in the Eating Disorder Inventory-2 and SOC as defined by Antonovsky in the SOC-29 scale. The hypothesis was that SOC should be negatively associated with perfectionism. Methods: Data from the two self-measuring instruments collected from 95 consecutively recruited eating disorder outpatients were analysed with descriptive and inferential statistics. Results: The patients in the present study scored consistently with other Swedish eating disorder samples on the Perfectionism subscale in the Eating Disorder Inventory-2 (EDI-P) and on the SOC-29, indicating a higher degree of perfectionism and weaker SOC than normal population groups. Perfectionism was significantly correlated to SOC. The correlation was negative, confirming the study hypothesis. The hypothesis was further confirmed in a subgroup analysis comparing patients with different degrees of SOC related to their EDI-P scores. Conclusions: Perfectionism is associated with SOC in patients with eating disorders. Clinical implications: The clinical implications derived from the study could be a recommendation to focus on the SOC in patients with an eating disorder with the hope of lowering the patients’ perfectionism as well

Perfectionism in Eating Disorders : Are Long-Term Outcomes Influenced by Extent and Changeability in Initial Perfectionism?

Purpose: Perfectionism has been found to predict outcomes in the treatment of eating disorders (ED). In the present study, we took advantage of longitudinal data to: a) investigate whether there are different patterns of perfectionism during the first six months after admission in a clinical sample of patients with ED, and b) describe how these patterns are related to long-term outcome. Methods: A sample of patients (N=294) from the Coordinated Evaluation and Research at Specialized Units for Eating Disorders database was divided into clusters according to perfectionism patterns measured with the EDI-2 perfectionism scale at baseline, and six months in treatment. Cluster analysis was performed on the extent and perseverance/changeability of self-oriented and socially described perfectionism. Outcome was measured with the EDI-2 and the SCL-63. Frequencies of eating disorder diagnoses were investigated. Results: Five clusters were identified. Low perfectionism was associated with lower levels of ED and psychiatric symptomatology at baseline. There were no significant differences between clusters on outcome variables at 36-month follow-up. Conclusions: Results indicated better psychiatric and psychological health three years after the initial measure. Patterns of relations between the extent and possible changes of perfectionism, measured with the EDI-P at baseline and after six months, did not appear to be associated with long-term outcomes on psychiatric health ratings

Perfectionism in Eating Disorders : Are Long-Term Outcomes Influenced by Extent and Changeability in Initial Perfectionism?

Purpose: Perfectionism has been found to predict outcomes in the treatment of eating disorders (ED). In the present study, we took advantage of longitudinal data to: a) investigate whether there are different patterns of perfectionism during the first six months after admission in a clinical sample of patients with ED, and b) describe how these patterns are related to long-term outcome. Methods: A sample of patients (N=294) from the Coordinated Evaluation and Research at Specialized Units for Eating Disorders database was divided into clusters according to perfectionism patterns measured with the EDI-2 perfectionism scale at baseline, and six months in treatment. Cluster analysis was performed on the extent and perseverance/changeability of self-oriented and socially described perfectionism. Outcome was measured with the EDI-2 and the SCL-63. Frequencies of eating disorder diagnoses were investigated. Results: Five clusters were identified. Low perfectionism was associated with lower levels of ED and psychiatric symptomatology at baseline. There were no significant differences between clusters on outcome variables at 36-month follow-up. Conclusions: Results indicated better psychiatric and psychological health three years after the initial measure. Patterns of relations between the extent and possible changes of perfectionism, measured with the EDI-P at baseline and after six months, did not appear to be associated with long-term outcomes on psychiatric health ratings

Initial self-blame predicts eating disorder remission after 9 years

Background Research into predictors of outcome in eating disorders (ED) has shown conflicting results, with few studies of long-term predictors and the possible importance of psychological variables that may act as risk- and maintenance factors. Aim To identify baseline predictors of ED remission nine years after initial clinical assessment using self-report measures of ED psychopathology, psychiatric symptoms, and self-image in a sample of adult ED patients (N = 104) treated at specialist units in Stockholm, Sweden. Sixty patients participated in the follow-up, of whom 41 patients (68%) had achieved remission. Results Results suggested that the only significant predictor of diagnostic remission after nine years was initial levels of self-blame. Conclusion In order to ensure long-term recovery in ED it may be important for clinicians to widen their therapeutic repertoire and utilise techniques that reduce self-blame and increase self-compassion. Plain English summary It is difficult to predict how an eating disorder will develop, and research has found varying factors that affect the outcome of the condition. Recovery rates vary from nearly nil to over 90%. This variation could be explained by different research factors, but are more likely due to varying definitions of recovery, with less stringent definitions yielding high recovery rates and more stringent definitions yielding lower rates. The present study investigated whether the severity of eating disorder symptoms and other psychiatric symptoms could predict recovery nine years from first admission to specialised eating disorder care. Sixty patients at three eating disorder treatment units participated, and their scores on self-report measures of symptoms were used as predictor variables. Forty-one participants had no eating disorder diagnosis at nine-year follow-up. Most participants with binge-eating disorder had recovered, while the poorest outcome was found for anorexia nervosa with slightly over half of patients recovered after nine years. The only predictor for the nine-year outcome was a higher initial rating of self-blame, measured with the Structural Analysis of the Social Behavior. It was concluded that it may be important for clinicians to detect and address self-blame early in the treatment of eating disorders in order to enhance the possibility of recovery. Treatment should focus on reducing self-blame and increasing self-acceptance.Funding Agencies|Kalmar Regional Council, Sweden</p

Using Personas in the development of eHealth interventions for chronic pain: A scoping review and narrative synthesis

Objectives: Behavioral eHealth interventions can enhance self-management and improve well-being in people with chronic pain. The development of these interventions calls for a user-centered approach to ensure that patient needs are appreciated. However, it may be challenging to involve patients; particularly during the early stages of the process. Fictional user profiles, known as Personas, can represent needs and guide designing eHealth interventions. This article provides a comprehensive overview of the use of Personas in the development of behavioral eHealth interventions for people with chronic pain with the aim to identify benefits and challenges. Methods: Bibliographic databases (Medline, Web of Science Core Collection, PsycInfo, CINAHL) and registries (PubMed Central, medaRxiv) were systematically searched. In a double-reviewing process, n = 6830 hits and n = 351 full-texts were screened and read. Ten peer-reviewed studies published between 2017 and 2022 were included in the narrative synthesis. Findings: Ten studies reported using “Pain Personas” in the development of eHealth interventions for such purposes as to gain a shared understanding of the user and to discuss solutions in team meetings, or for patients to identify with (if Personas are included in the intervention). Personas were based on qualitative and/or quantitative data. However, the procedure for creating Personas was only described in half of the included studies (n = 5). These five studies provided descriptive details of the Personas (i.e., picture, name, narrative of their pain behavior, technological skills, and motivation). Conclusions: Although Personas have been used by pain researchers in recent projects and were highlighted as an important ingredient in the development process, available design guidelines for the creation and use of Personas are not followed or communicated transparently. Benefits and challenges when using Personas in the development of eHealth interventions for people with chronic pain are discussed to support future eHealth efforts and to improve the quality of eHealth innovation in the field of pain

Development, evaluation and implementation of a digital behavioural health treatment for chronic pain : study protocol of the multiphase DAHLIA project

Introduction: Chronic pain affects about 20%-40% of the population and is linked to mental health outcomes and impaired daily functioning. Pharmacological interventions are commonly insufficient for producing relief and recovery of functioning. Behavioural health treatment is key to generate lasting benefits across outcome domains. However, most people with chronic pain cannot easily access evidence-based behavioural interventions. The overall aim of the DAHLIA project is to develop, evaluate and implement a widely accessible digital behavioural health treatment to improve well-being in individuals with chronic pain. Methods and analysis: The project follows the four phases of the mHealth Agile Development and Evaluation Lifecycle: (1) development and pre-implementation surveillance using focus groups, stakeholder interviews and a business model; (2) iterative optimisation studies applying single case experimental design (SCED) method in 4-6 iterations with n=10 patients and their healthcare professionals per iteration; (3) a two-armed clinical randomised controlled trial enhanced with SCED (n=180 patients per arm) and (4) interview-based post-market surveillance. Data analyses include multilevel modelling, cost-utility and indicative analyses. In October 2021, inter-sectorial partners are engaged and funding is secured for four years. The treatment content is compiled and the first treatment prototype is in preparation. Clinical sites in three Swedish regions are informed and recruitment for phase 1 will start in autumn 2021. To facilitate long-term impact and accessibility, the treatment will be integrated into a Swedish health platform (www.1177.se), which is used on a national level as a hub for advice, information, guidance and e-services for health and healthcare. Ethics and dissemination: The study plan has been reviewed and approved by Swedish ethical review authorities. Findings will be actively disseminated through peer-reviewed journals, conference presentations, social media and outreach activities for the wider public

Content validity of global measures for at-work productivity in patients with rheumatic diseases: an international qualitative study.

To identify from a patient's perspective, difficulties and differences in the comprehension of five global presenteeism measures in patients with inflammatory arthritis and OA across seven countries