Accepted Manuscript

An examination of direct, indirect and reciprocal relationships

between perfectionism, eating disorder symptoms, anxiety, and
depression in children and adolescents with eating disorders

Haans Drieberg, Peter M. McEvoy, Kimberley J. Hoiles, Chloe Y.

Shu, Sarah J. Egan

PII: S1471-0153(18)30232-0
DOI: https://doi.org/10.1016/j.eatbeh.2018.12.002
Reference: EATBEH 1271
To appear in: Eating Behaviors
Received date: 2 July 2018
Revised date: 14 December 2018
Accepted date: 14 December 2018

Please cite this article as: Haans Drieberg, Peter M. McEvoy, Kimberley J. Hoiles, Chloe
Y. Shu, Sarah J. Egan , An examination of direct, indirect and reciprocal relationships
between perfectionism, eating disorder symptoms, anxiety, and depression in children
and adolescents with eating disorders. Eatbeh (2018), https://doi.org/10.1016/
j.eatbeh.2018.12.002

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PERFECTIONISM IN EATING DISORDERS
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An examination of direct, indirect and reciprocal relationships between perfectionism, eating

disorder symptoms, anxiety, and depression in children and adolescents with eating disorders.

Haans Drieberg, BPsych(Hons), MPsych(Clin)1

Peter M. McEvoy, MPsych(Clin), PhD1, 2

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*Kimberley J. Hoiles, MPsych(Clin), PhD3

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Chloe Y. Shu, MPsych(Clin), PhD3

Sarah J. Egan, MPsych(Clin), PhD1

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School of Psychology, Curtin University, Perth, Australia
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Centre for Clinical Interventions, Perth, Australia
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3
Eating Disorders Program, Child and Adolescent Health Service, Perth, Australia
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*Corresponding author (K. J. Hoiles) at: Eating Disorders Program, Child and Adolescent
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Health Service, Perth Childrens Hospital, Locked Bag 2010, Nedlands, Australia, 6909.
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Email address: Kimberley.Hoiles@health.wa.gov.au

Declarations of interest: none.

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Abstract

Objective: Perfectionism is a transdiagnostic factor across eating disorders, anxiety, and

depression. Previous research has shown anxiety mediates the relationship between

perfectionism and eating disorders in adults. The aim of this study was to investigate the

relationships between anxiety/depression, perfectionism and eating disorder symptoms in

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children and adolescents with eating disorders.

Method: Structural equation modeling was used to investigate three models in a clinical

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sample of children and adolescents (N = 231, M age = 14.5, 100% female): (1) anxiety and

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depression as mediators of the relationship between perfectionism and eating disorder
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symptoms, (2) eating disorder symptoms as a mediator of the relationship between

perfectionism and anxiety and/or depression, and (3) perfectionism as a mediator of the
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relationship between anxiety/depression and eating disorders.

Results: Results indicated that both models 1 and 2 fit the data well, while model 3 provided
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a poor fit. These findings suggest that in clinical populations of children and adolescents,
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anxiety and depression mediate the relationship between perfectionism and eating disorder
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symptoms, and there is also a reciprocal relationship whereby eating disorders mediate the
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association between perfectionism, and anxiety and/or depression.

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Discussion: The results highlight the importance of further research to determine whether

targeting perfectionism is helpful in the treatment of eating disorders and comorbid anxiety

and depression in young people. It would be useful for clinicians to consider assessing for

and treating perfectionism directly when it is elevated in children and adolescents with eating

disorders.

Keywords: perfectionism, eating disorders, children, adolescents, HOPE Registry

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An examination of direct, indirect and reciprocal relationships between perfectionism, eating

disorder symptoms, anxiety and depression in children and adolescents with eating disorders.

Adolescence is a period associated with an elevated risk of developing an eating

disorder (Ferreiro, Wichstrøm, Seoane, & Senra, 2014; Torstveit, Aagedal-Mortensen, &

Stea, 2015). It is well established that individuals with eating disorders have a high

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prevalence of comorbid anxiety and depression (Arlt et al., 2016; Hughes et al., 2013;

Koutek, Kocourkova, & Dudova, 2016; Pallister & Waller, 2008). In children and

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adolescents with eating disorders, perfectionism has been found to be associated with higher

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anxiety, depression (Morgan-Lowes et al., 2018), eating disorder symptoms and lower

remission (Johnston et al., 2018).

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Perfectionism has been proposed to be a transdiagnostic process elevated across
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eating disorders, anxiety, and depression (Egan, Wade, & Shafran, 2011), which has been

supported by a recent meta-analysis (Limburg, Watson, Hagger, & Egan, 2017). While all
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aspects of perfectionism measures have been found to be related to eating disorders (Limburg
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et al., 2017), several studies have found that a subscale of the Multidimensional
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Perfectionism Scale (Frost, Marten, Lahart, & Rosenblate, 1990), concern over mistakes, is

particularly strongly associated with eating disorder symptoms (e.g., Bulik et al., 2003; Wade
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et al., 2008). Clinical perfectionism, where self-worth is based on achievement despite

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adverse consequences (Shafran, Cooper, & Fairburn, 2002), is a key maintaining mechanism

in the transdiagnostic model of eating disorders (Fairburn, Cooper, & Shafran, 2003). Despite

robust evidence for a relationship between eating disorders and perfectionism, the nature of

this association is not well understood (Bardone-Cone et al., 2007) and a deeper

understanding, particularly of the indirect factors that may mediate this relationship, is

required.
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In an examination of mediating variables, Egan et al. (2013) found in a sample of

adults that anxiety partially mediated the relationship between perfectionism and eating

disorders. The absence of full mediation suggested that additional variables play a role in

accounting for this relationship. Given that depression is also strongly associated with eating

disorders and perfectionism (Egan et al., 2011; Limburg et al., 2017), it is appropriate to

investigate whether depression plays a similar mediating role to anxiety. For example, it

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would be useful to examine in children and adolescents if eating disorder symptoms arise out

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of an initial depressive or anxious state, and likewise the reverse relationship. In adolescents

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there is evidence of a link between perfectionism and eating disorder symptoms (e.g., Boone,

Soenens, & Luyten, 2014), as well between depression, anxiety and perfectionism (e.g.,
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Affrunti & Woodruff-Borden, 2014; Mitchell, Newall, Broeren, & Hudson, 2013). Research

in adolescents has also demonstrated a link between eating disorders and anxiety/depression
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(e.g., Holm-Denoma, Hankin, & Young, 2014). Despite these associations, there has been no

examination to date of whether anxiety and depression mediate the relationship between
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perfectionism and eating disorders in a clinical sample of children and adolescents with
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eating disorders. There is also literature suggesting that the relationship between eating

disorders and depression and/or anxiety may be bi-directional (Micali et al., 2015; Puccio,
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Fuller-Tyszkiewicz, Ong, & Krug, 2016). There is emerging evidence that eating disorders

and anxiety/depression are genetically correlated, with evidence for shared genetic
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components between these disorders (e.g., Brainstorm Consortium et al., 2018; Dellava,

Kendler, & Neale, 2011). Hence it would be useful to further examine the relationships

between symptoms of eating disorders, anxiety and depression and their relationship with

perfectionism. Furthermore, given research which has found perfectionism to be a mediator

of various psychopathologies (Egan et al., 2011), there is also a rationale for investigating if

perfectionism is a mediator between anxiety/depression and eating disorders.

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The aim of this study was to examine the relationships between perfectionism,

anxiety, depression, and eating disorder symptoms in children and adolescents with eating

disorders. Given the findings of Egan et al. (2013), which demonstrated the indirect effect of

anxiety on the relationship between perfectionism and eating disorder pathology in adults, we

predicted a similar indirect effect in children and adolescents. Specifically, we hypothesised

an indirect effects model where perfectionism predicts eating disorder symptoms through

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anxiety and depression. The direct effect between perfectionism and eating disorder

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symptoms was freed within Model 1 (Figure 1, top). For the alternative Model 2 (Figure 1,

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middle), based on the findings of Micali et al. (2015), we hypothesised an indirect effects

model where perfectionism predicts anxiety and depression via eating disorder symptoms
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would also provide an adequate fit to the data. Direct effects from perfectionism to anxiety

and depression were also freed within the model. Finally, we also investigated a final
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alternate model (Model 3, Figure 1, bottom) where it was hypothesised that anxiety and

depression would predict eating disorder symptoms through perfectionism.

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Anxiety

Eating Disorder

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Perfectionism Symptoms

Depression

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Anxiety

Eating Disorder
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Perfectionism
Symptoms

Depression
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Anxiety

Eating Disorder
Perfectionism Symptoms
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Depression

Figure 1: Structural Equation Model 1 (top), Model 2 (middle), and Model 3 (bottom). Direct
and indirect pathways between perfectionism, anxiety, depression, and eating disorder
symptoms
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Method

Participants

Participants were 231 females aged 11.0 to 17.8 (M = 14.5, SD = 1.24). Data were

derived from the Helping to Outline Paediatric Eating Disorders (HOPE) registry. The

registry comprises a sequential cross-sectional sample collected from 1996 to the present at

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the Child and Adolescent Health Services Eating Disorders Program, located at Perth

Children’s Hospital. Data originated from routine intake assessments and was entered into the

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registry after informed consent was obtained. Our sample comprised patients who were

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included in the HOPE database since 2012, when the collection of the key measure, Eating

Disorder Inventory version 3 (EDI-3; Garner, 2004) commenced. Inclusion criteria were:
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females, first presentation at the service, and a Diagnostic and Statistical Manual (DSM-5;
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American Psychiatric Association, 2013) eating disorder diagnosis. Ethical approval was

granted by the Child and Adolescent Health Services Human Research Ethics Committee
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(2042/EP), and Curtin University Human Research Ethics Committee (HRE2017-0148).

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Measures
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Eating Disorder Inventory, version 3 – Perfectionism (EDI-P; Garner, 2004). The

EDI-P is a six-item self-reported scale of the EDI-3 designed to assess trait perfectionism.
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Items are scored from 1-6 with higher scores corresponded with higher levels of
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perfectionism. Despite initially being developed as a unidimensional measure of

perfectionism, there is evidence that it consists of two factors, self-oriented and socially-

prescribed perfectionism (Lampard, Byrne, McLean, & Fursland, 2012; Sherry, Hewitt,

Besser, McGee, & Flett, 2004). The EDI-P is the most frequently used measure of

perfectionism in eating disorder samples (Bardone-Cone et al., 2007), has good validity

(Friborg, Clausen, & Rosenvinge, 2013), and in the current study had good internal

consistency (α = .80).
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Adapted version of The Eating Disorder Examination (EDE; Fairburn & Cooper,

1993). The EDE is a semi-structured interview that generates a global eating disorder

symptoms score, as well as four subscales: Restraint, Eating Concern, Shape Concern and

Weight Concern. The adapted measure for children and adolescents is similar but not

identical to the ChEDE (Bryant‐Waugh, Cooper, Taylor, & Lask, 1996) and was used as the

service pre-dated ChEDE publication. The adapted version of the EDE has acceptable

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reliability and validity (O'Brien et al., 2016). The current sample had acceptable internal

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consistency (restraint α = .79, eating concern α = .80, shape concern α = .92, weight concern

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α = .88, global α = .95).

Multidimensional Anxiety Scale for Children 2 (MASC 2; March, 2012). The MASC 2
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is a widely used self-report measure of anxiety across four factors: physical symptoms, harm

avoidance, social anxiety, and separation/panic. Because components of the harm avoidance
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subscale measure characteristics of perfectionism (March, Parker, Sullivan, Stallings, &

Conners, 1997) it was excluded as an indicator of anxiety in the current study. The MASC 2
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had excellent internal consistency in the current sample (α = .92). The MASC 2 has also
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demonstrated divergent validity by discriminating between depression and anxiety in an

adolescent clinical sample (March, 2012). Norms for the MASC have been reported in
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children and adolescents with eating disorders (Watson, Egan, Limburg, & Hoiles, 2014b).

Two-thirds (66%) of the current sample was assessed using the MASC (March et al., 1997)
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which was employed prior to changing to the MASC 2. Comparing the MASC to the MASC

2, subscales relevant to the current study are comprised of identical items, therefore

maintaining consistency in the current sample.

Children's Depression Inventory 2 (CDI 2; Kovacs, 2011). The CDI 2 is a 27-item

self-reported scale that assesses depressive symptoms across four subscales: negative

mood/physical symptoms, ineffectiveness, negative self-esteem, and interpersonal problems.

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The scale had excellent internal consistency in this sample (α = .94). Norms for the CDI have

been reported in children and adolescents with eating disorders (Watson, Egan, Limburg, &

Hoiles, 2014a). Prior to 2014, the HOPE database employed the CDI (Kovacs, 1985). For the

current study, all CDI values have been converted to CDI 2 values in accordance with the

conversion protocol recommended by Kovacs (2011).

Statistical analysis

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Descriptive analyses were conducted with SPSS version 21. Structural models using

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robust maximum likelihood (MLR) estimation were run using Mplus version 8.1 with Full

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Information Maximum Likelihood (FIML) used to account for missing data (Muthén &

Muthén, 2017). EDI-P items were used as indicators of perfectionism, with items 1 (Only
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outstanding performance is good enough in my family) and 4 (My parents have expected

excellence of me) freed to covary because they assess family expectations. Three models
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were tested. Model 1 tested direct and indirect effects from perfectionism to eating disorder

symptoms via anxiety and depression. Model 2 tested an alternative model whereby
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perfectionism led to eating disorder symptoms, which then led to anxiety and depression.
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Model 3 tested direct and indirect effects from anxiety and depression to perfectionism,

which, in turn, led to eating disorder symptoms. Anxiety and depression were free to covary
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in all models. Bootstrapped 95% confidence intervals from 1000 resamples were calculated

around all direct and indirect effects parameters. Goodness-of-fit between the observed data
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and the two hypothesised models was assessed using the χ2 test, Comparative Fit Index (CFI),

Tucker-Lewis Index (TLI), Root Mean Square Error of Approximation (RMSEA), and the

Standardized Root Mean Square Residual (SRMR). Model fit indices were adopted from Hu

and Bentler (1999). The Akaike Information Criterion (AIC) and Bayesian Information

Criterion (BIC) were used to compare non-nested models, with differences of 10 or more
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providing very strong evidence supporting the model with the smallest value (Fabozzi,

Focardi, Rachev, & Arshanapalli, 2014).

Power estimates for SEM are complex and depend on a range of factors, including the

magnitude of parameter estimates, sample size, missing data, bias in parameter estimates, and

solution propriety (convergence), which renders ‘recommended’ sample size guidelines

problematic (Wolf, Harrington, Clark, & Miller, 2013). Given the difficult to access sample

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used in this study, and resultant fixed sample size, we estimated the power of structural

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parameters in our model post hoc using Monte Carlo simulations with 10,000 replications.

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These simulation provided estimates of coverage (proportion of replications for which the

95% confidence intervals contained the true parameter value; values should be >.90, Wolf et
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al., 2013) and power for each structural parameter (the proportion of replications for which

the null hypothesis that a parameter is equal to zero is rejected for each parameter at α = .05).
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If power fell below .80 on any structural parameter, we also increased the sample size within

these simulations to 500 and 1000 to determine the required sample size to achieve .80
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power.
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Results

Table 1 shows the clinical characteristics and demographics of the sample, which
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primarily comprised anorexia nervosa-type presentations.

Table 1
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Clinical Characteristics and Demographics of the sample (N = 231)

Variable n (%) M, Range SD

Age (years) 14.5, 11.0 - 17.8 1.24

Birthplace 223
- Australia 176 (78.9) - -
- Europe 25 (11.2) - -
- Africa 11 (4.9) - -
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- Asia 6 (2.7) - -
- America 3 (1.3) - -
- NZ/Oceania 1 (0.4) - -
- Other 1 (0.4) - -
Weight (kg) 44.4, 24.6 - 80.0 8.18
Height (metres) 1.62, 1.35 - 1.82 0.07
Body Mass Index (kg/m2) 16.8, 11.8 - 27.3 2.54

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Currently taking psychiatric medication 50 (21.6) - -

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MASC 2 score 45.8, 0 - 81 17.3
CDI 2 score 25.0, 0 - 52 12.7

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EDE global score (0-6) 3.52, 0 - 5.95 1.53
- Restraint (0-6) 3.76, 0 - 6.00 1.63
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- Eating concern (0-6) 2.95, 0 - 5.80 1.59
- Shape concern (0-6) 3.96, 0 - 6.00 1.70
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- Weight concern (0-6) 3.42, 0 - 6.00 1.81

EDI-P score 22.9, 6 - 36 6.46
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DSM-5 eating disorder diagnosis:

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- AN-R 83 (35.9) - -
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- AN-BP 16 (6.9) - -
- BN 20 (8.7) - -
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- OSFED: -
- Aty-AN 68 (29.4) - -
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- BN-LF/LD 8 (3.5) - -
- PD 1 (0.4) - -
- UFED 35 (15.2) - -
Note: MASC 2 = Multidimensional Anxiety Scale for Children score based on physical
symptoms, social anxiety, and separation/panic subscales (March, 2012), CDI 2 = Child
Depression Inventory score based on the Total CDI 2 (Kovacs, 2011), EDE = Eating
Disorder Examination (Fairburn & Cooper, 1993), EDI-P = Eating Disorder Inventory –
Perfectionism (Garner, 2004), DSM-5 = Diagnostic and Statistical Manual of Mental
Disorders – Fifth Edition, AN-R = anorexia nervosa – restricting, AN-BP = anorexia
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nervosa – binge/purge, BN = bulimia nervosa, OSFED = other specified feeding or eating

disorders, Aty-AN = atypical anorexia nervosa, BN-LF/LD = bulimia nervosa – low
frequency and/or limited duration, PD = purging disorder, UFED = unspecified feeding or
eating disorders

All correlations (Table 2) were statistically significant, (p .01), supporting the

viability of the indirect effects models. Fit statistics for Model 1 indicated acceptable but not

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excellent fit across multiple indices (see Model 1 in Table 3, Figure 2). Model 2 provided a

similar fit to Model 1. Modification indices were observed for both models, but did not reveal

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areas of substantial model strain and freeing up more parameters in the model was not

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deemed to be theoretically defensible. Model 3 provided a poor fit to the data across all

indices, so was not considered further. AIC and BIC did not distinguish between Models 1
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and 2, but Model 3 provided the worst fit.
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Table 2

Correlations Among Scale Scores (N = 231)

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Perfectionism Anxiety Depression

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Perfectionism -
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Anxiety 0.27* -
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Depression 0.32* 0.76* -

Eating disorder
0.35* 0.66* 0.77*
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symptoms

Note: Perfectionism = EDI-P (Garner, 2004), Anxiety = MASC 2 (March, 2012) (based on
physical symptoms, social anxiety, and separation/panic subscales), Depression = CDI 2
(Kovacs, 2011), Eating Disorder Symptoms = EDE global score (Fairburn & Cooper, 1993).
* p < .01
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Table 3. Goodness of fit indices for structural equation models.

Model χ2 (df) CFI TLI RMSEA (90% CI) SRMR AIC BIC

Model 1 327.58 (112) .911 .892 .091 (.080-.103) .073 15689 15889

Model 2 328.19 (114) .912 .894 .090 (.079-.102) .074 15686 15880

Model 3 499.87 (114) .841 .810 .121 (.110-.132) .157 15854 16047

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For Model 1 (Figure 2), the indirect pathway between perfectionism and eating

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disorder symptoms via depression was significant (.21, p = .03). However, the indirect

pathway between perfectionism and eating disorder symptoms via anxiety was non-
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significant (.11, p = .22). This model explained a significant proportion of variance in anxiety
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(17%, p = .01), depression (16%, p = .01) and eating disorder symptoms (71%, p .001).

For Model 2 (Figure 3), the indirect pathway between perfectionism and anxiety via
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eating disorder symptoms was significant (.36, p .001). In addition, the indirect pathway
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between perfectionism and depression was significant (.37, p .001). This model explained a
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significant proportion of variance in anxiety (66%, p .001), depression (69%, p .001) and

eating disorder symptoms (19%, p = .003).

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Models 1 and 2 were re-run controlling for Body Mass Index (BMI) as a proxy for
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starvation state on eating disorder symptoms only, and then on all intermediate and outcome

variables. BMI was a significant predictor of anxiety, depression, and eating disorder

symptoms in Model 1, but only eating disorder symptoms (not anxiety and depression) in

Model 2. Importantly, the pattern of significant relationships among the primary constructs of

interest did not change at all for any model, so only the models without BMI are reported.

Finally, we ran Monte Carlo simulations on Models 1 and 2. For Model 1, coverage

was ≥ .94 for all structural parameters. Power ranged between .25 (anxiety predicting eating
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PERFECTIONISM IN EATING DISORDERS
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disorder symptoms) to .99 (anxiety and depression predicting perfectionism). Increasing the

sample size to 500 increased power for the anxiety-eating disorder pathway to .55, and a

sample of 1000 increased power to .84 (.83 for the indirect effect of perfectionism-anxiety-

eating disorder symptoms). For Model 2, coverage was ≥ .94 and power was 1.00 for all

structural parameters.

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MASC-PS MASC-SA MASC-SP

T
.86** .74**
.42**
EDI1

I P
R EDE-R

SC
EDI2 .61**
Anxiety
.27 (-.16, .70) .80**

.47** .42** (.25, .58)

.85**

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.90** (.83, .97) EDE-E
EDI3

N
.74** .11 (-.01, .22) Eating Disorder
.93**
Perfectionism Symptoms
EDI4
.42**

.74** .40** (.24, .55)

M A .54* (.13, .95)
.92**
EDE-S

Depression
EDI5 .63**

E D EDE-W

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.84** .74**
EDI6
.89** .89**

C E CDI-NM CDI-NSI CDI-IE CDI-P

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Figure 2: Standardised path coefficients for Model 1, with 95% confidence intervals in parentheses. EDI = Eating Disorder Inventory, CDI =
Children’s Depression Inventory 2 (subscales: NM = negative mood, NSI = negative self-esteem, IE = ineffectiveness, IP = interpersonal
problems), EDE = Eating Disorder Examination (subscales: R = restraint, E = eating concern, S = shape concern, W = weight concern); MASC
= Multidimensional Anxiety Scale for Children 2 (subscales: PS = physical symptoms, SA = social anxiety, SP = separation anxiety/panic), * p<
.05; ** p < .001.
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MASC-PS MASC-SA MASC-SP

T
EDE-R EDE-E EDE-S .86** .74**
EDE-W .42**

P
EDI1

EDI2
.80**
.85** .93**
.92**
R I Anxiety

C
.61**

S
.48**
.44** (.29, .59)
EDI3
.74**

.43**
Perfectionism
Eating Disorder

N
Symptoms U .81** (.74, .88)
.74** (.59, .90)

A
.83** (.78, .88)
EDI4

M
.73**

.63** Depression

D
EDI5

E
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EDI6 .84** .74**
.89**
.89**

C E CDI-NM CDI-NSI CDI-IE CDI-P

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Figure 3: Standardised path coefficients for Model 2, with 95% confidence intervals in parentheses. EDI = Eating Disorder Inventory, CDI =
Children’s Depression Inventory 2 (subscales: NM = negative mood, NSI = negative self-esteem, IE = ineffectiveness, IP = interpersonal
problems), EDE = Eating Disorder Examination (subscales: R = restraint, E = eating concern, S = shape concern, W = weight concern); MASC
= Multidimensional Anxiety Scale for Children 2 (subscales: PS = physical symptoms, SA = social anxiety, SP = separation anxiety/panic), ** p
< .001.
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Running head: PERFECTIONISM IN EATING DISORDERS

Discussion

The aim of this study was to examine if anxiety and depression mediated the

relationship between perfectionism and eating disorder symptoms in female children and

adolescents diagnosed with an eating disorder. As hypothesised, a significant indirect

relationship was found between perfectionism and eating disorder symptoms via depression,

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indicating that depression mediated the relationship. In addition, a significant direct

relationship was found between perfectionism and eating disorders symptoms. These findings

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indicate that higher perfectionism is associated with more severe eating disorder symptoms

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directly, but also because of the association perfectionism has with depression. Contrary to

our expectations, anxiety was not a significant mediator of the relationship between
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perfectionism and eating disorder symptoms. This result is inconsistent with Egan et al.

(2013), who found that anxiety partially mediated this relationship in adults. While our
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finding may be due to differences in presentations of anxiety in children and adolescents, it

may also be related to the sample size in our study. The weak indirect relationship between
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perfectionism and eating disorder symptoms via anxiety observed by Egan et al. (2013) was
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similar to the current study (.11) yet the sample used by Egan et al. was considerably larger

(N = 369 vs. N = 231). Comparability of the magnitudes of the indirect effect coefficients
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from these two studies is consistent with the notion that sample size was a factor in the
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statistically non-significant result for anxiety in the current study. Simulations suggested that

we would have needed a sample size of almost 1000 for 80% power to detect this effect.

The second model, where eating disorder symptoms mediated the relationship

between perfectionism and anxiety/depression, had a similar goodness to fit to the first

model. This suggests that the relationship between anxiety/depression and eating disorders

is reciprocal in nature, consistent with previous research (e.g., Boujut & Gana, 2014; Ranta

et al., 2017), and supports the notion of perfectionism as a transdiagnostic process (Egan et
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Running head: PERFECTIONISM IN EATING DISORDERS

al., 2011; Limburg et al., 2017). However, the two models explained substantially different

proportions of variance. Model 1 where depression was a mediator between perfectionism

and eating disorders, accounted for 74% of the variance in eating disorder symptoms, 18% of

anxiety, and 17% of depression. Conversely, in Model 2, where eating disorder symptoms

were a mediator between perfectionism and anxiety/depression, accounted for only 22% of

the variance in eating disorder symptoms, but 69% of anxiety and 70% of depression. Model

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3, where perfectionism was a mediator of the relationship between anxiety/depression and

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eating disorder symptoms, provided a poor fit for the data. Notwithstanding the cross-

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sectional data and need to be cautious making causal conclusions, if researchers are primarily

concerned with predicting eating disorder symptoms, Model 1 may be preferred, whereas if
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predicting anxiety/depression is of interest, Model 2, would be superior. It is possible that the

relationships between perfectionism, eating disorder symptoms, and anxiety and depression
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observed in our sample were symptomatic of a starvation state, and it’s associated impacts on

factors such as cognitive rigidity. However, controlling for BMI as a proxy for starvation
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state in the models did not alter the pattern of relationships in any of the models. These
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findings lend some support to the importance of perfectionism and its relationship with
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symptoms of eating disorders and anxiety and depression independent of BMI.

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The strength of the direct effects between perfectionism and symptoms suggest that, if

these current findings were replicated in prospective and experimental studies, it would be
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useful to determine whether targeting perfectionism in youths with eating disorders is

associated with a transdiagnostic effect in reducing eating disorder symptoms, as well as

anxiety and depression. Likewise, given the bi-directional relationships, future research could

examine whether treating anxiety and depression results in reductions in comorbid eating

disorder pathology, and conversely, whether treating eating disorder symptoms reduces

depression and anxiety. A recent meta-analysis by Linardon, Wade, de la Piedad Garcia, and
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Running head: PERFECTIONISM IN EATING DISORDERS

Brennan (2017), which indicated that greater improvements in depressive symptoms during

cognitive behaviour therapy (CBT) for bulimia nervosa may be explained by greater

improvements in eating disorder symptoms in adults, provides some validation of the utility

of such therapeutic directions. Similarly, evidence suggests that Cognitive-Behaviour

Therapy-Enhanced (CBT- E; Fairburn, 2008), which targets perfectionism when elevated, has

efficacy in the treatment of eating disorders in adolescents. Further, in addition to CBT for

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perfectionism having efficacy in the reduction of eating disorder symptoms in adults (Steele

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& Wade, 2008), a pilot study has indicated efficacy in reducing eating disorder symptoms in

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female adolescents with anorexia nervosa (Hurst & Zimmer‐Gembeck, 2015). It would be

valuable for future research to compare CBT for perfectionism with evidence-based disorder-
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specific treatments in children and adolescents to determine if CBT for perfectionism is able

to treat the eating disorder equally effectively, but result in larger reductions in comorbid
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anxiety and depression, as seen in adult samples (Steele & Wade, 2008).

There are several limitations of the study. First, temporal precedence (i.e., prospective
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data) is necessary (but not sufficient) to infer causality between variables, but the cross-
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sectional design of this study does not provide us with such information. Future studies
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should consider longitudinal and experimental designs to enable a clearer picture of whether
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perfectionism leads to anxiety and depression, which then causes some individuals to develop

eating disorders, or whether perfectionism causes eating disorders, which then leads to
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anxiety and/or depression. A second limitation is generalisability of the findings, which are

based on a treatment-seeking, female, clinical population, at a tertiary treatment setting.

Future research accounting for a wider range of cultures/ethnicities, populations not in

treatment, as well as males is warranted. Third, almost all of the hypothesised pathways were

statistically significant, suggesting that power was not a critical concern. It is also noteworthy

that Monte Carlo simulations suggested that a sample size of almost 1000 would have been
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Running head: PERFECTIONISM IN EATING DISORDERS

required to achieve .80 power to detect a significant effect for the pathway with the lowest

power (anxiety to eating disorder symptoms in Model 1). However, the confidence intervals

for some parameters were wide, and the relatively weak pathways from anxiety to eating

disorder symptoms, and from perfectionism to eating disorder symptoms, may have achieved

statistical significance in a larger sample. Future research with more statistical power and

thus potential for greater precision in estimates should investigate this possibility, along with

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the relative strengths of associations between the pathways.

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In conclusion, the study provides support for the transdiagnostic nature of

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perfectionism. This highlights the importance of further research to determine whether

directly targeting perfectionism will be helpful in the treatment of eating disorders and
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comorbid anxiety and depression in children and adolescents. If perfectionism is elevated in

a young person with an eating disorder, clinicians may consider including this factor as a
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relevant target in formulation and treatment.

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Declarations of interest: The authors have no conflicts of interest to report

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Acknowledgments: The HOPE Project is supported by a Department of Health in Western

Australia Targeted Research Fund grant.

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Highlights:

In children and adolescents:

 Anxiety mediates the relationship between perfectionism and eating disorder

symptoms

 Depression mediates the relationship between perfectionism and eating disorder

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symptoms

 Eating disorders mediate the relationship between perfectionism and anxiety, and/or

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depression

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