The relationship between shame, perfectionism and Anorexia Nervosa: a grounded theory study

Objectives The aim of this study was to explore the potential relationship between shame, perfectionism and Anorexia Nervosa (AN) and their impact on recovery from AN.

Method Semi-structured interviews were conducted with 11 people currently accessing services for AN. Interviews were transcribed and analysed using constructivist-grounded theory methodology.

Results A model was developed which found a vicious cycle between shame and perfectionism. Participants tried to alleviate their feelings of shame by striving for perfectionism, however failing caused them more shame.

Participants who disclosed childhood trauma believed their shame preceded their perfectionism. Participants who did not disclose trauma either believed their perfectionism preceded shame or they were unsure of which occurred first.

Participants' responses suggested the following pathways from perfectionism to AN: needing goals; the need for a perfect life including a perfect body and AN being something they could be perfect at. The pathways identified between shame and AN entailed mechanisms via which AN could be used to escape shame, either by seeking pride through AN, seeking to numb shame through AN, seeking to escape body shame and punishing the self. AN was found to feed back into shame in two ways: when people had AN they felt ashamed when they broke their dietary rules, and also simultaneously people felt ashamed of their AN as they were not able to recover.

Shame and perfectionism influenced one another in a cyclical pattern, in which shame drove perfectionism and not attaining high standards led to shame. Shame and perfectionism also impacted on recovery in several ways. AN functioned to numb participants' emotions, becoming part of their identity over time. AN also brought respite from a constant striving towards perfectionism. The need for a perfect recovery also influenced their motivation to engage in treatment, and fear of a return of strong emotions was another deterrent to recovery.

Conclusion The findings of this paper show perfectionism and shame to both be important in the aetiology and maintenance of AN and to have an impact on recovery from AN.