Almost every recent book or article written on eating disorders cites perfectionist tendencies as being a predisposing factor in developing AN. You will often hear therapists referring to perfectionism as a negative character trait closely associated with obsessive-compulsive disorder. Words like "chronic pleaser" or "obsessive" are used to describe the personality of the anorexic person.
Dictionaries vary in their definition of the word, but Reader's Digest Encyclopedic Dictionary defines a perfectionist as "One who demands of himself or others an exceedingly high degree of excellence." Most of us realize that perfection is unattainable in a physical world. But striving for excellence is not something that I would call a negative character trait. In fact, our society is very intolerant of anyone who is not a perfectionist. No one wants to listen to a vocalist that sings slightly out of tune, or buy a car that has small defects in the paint job. We expect aircraft mechanics to be perfectionists, as our very lives depend on them working without any errors or omissions. Any athlete that wants to excel at competition must strive for excellence. Anyone who is not a perfectionist will not excel at sports, business, work, or music.
It is generally observed, however, that anorexic patients generally do excel at many pursuits. They generally have a history of high achievement or academic success. The conventional wisdom sees this high achieving trait as one of the causes of carrying the weight-loss to extremes. It is easy to understand how the therapist could believe this, since the assumption is made that there is nothing physically wrong with the patient. The patient may even insist they want to lose more weight (this may be an excuse for their refusal to eat, since most eating disorder programs refuse to accept the "I'm not hungry" or "I don't feel well" excuses). One of the goals of cognitive-behavioral therapy is to convince the patient that they don't need to pursue excellence, and that it is OK to fail or not do your best. Achieving "objective reality" is the desired outcome.
The vast majority of high achievers do not develop eating disorders, however, I believe the tendency to pursue excellence could be a factor in the development of AN, since the high acheiver is used to pushing themselves to their limits. A chronic digestive disorder will make this type of person vulnerable to becoming malnourished if they start dieting or engaging in competitive sports. This is because they will find it very easy to lose weight. For an athlete involved in high strength-to-weight ratio sports (distance running, ballet, gymnastics), the first stages of weight loss combined with exercise will provide a significantly higher strength-to-weight ratio. This will intially improve their performance, since as their body mass drops the muscles do not decrease proportionally in strength, and in fact initially will increase in strength. The anorexic individual may be encouraged in their pursuit by this initial success.
The high strength-to-weight ratio allows them to do increasingly more exercises, since there is now much less body mass to lift and accelerate. As malnutrition progresses, the anorexic, now adapted to their unknown digestive tract disorder, also adapts to the lack of nutrition. Due to this adaptation, they may be totally unaware that there is something wrong with their body. If their goal was an ideal body shape, no matter how hard they try, they cannot acheive it because the bloating makes their stomach look fat, and the skinnier they get the bigger the stomach looks in comparison. If they are used to pushing themselves to the limit of their endurance, they will not give up so easily. Maybe more exercise will flatten that tummy, or improve athletic performance.
Once malnutrition reaches an advanced state, the brain becomes so preoccupied with correcting the nutritional deficiency, a hyperactivity starvation response can ensue, making the patient very agitated and wanting to exercise to alleviate the agitation (see starvation response). Of course, if an otherwise healthy individual becomes malnourished, this hyperactivity and preoccupation with food serves a positive purpose, since it increases the likelihood of finding food. The otherwise healthy malnourished person would then consume this food and gradually gain body mass. The person with a chronic digestive tract disorder, however, may be unable to eat, as they often experience early satiety, nausea, bloating, or stomach pain when they try to eat.
You can see that the high achieving athlete or dieter with an undiagnosed digestive disorder is in serious trouble. Unless steps are taken to identify and treat the underlying disorder, malnutrition is likely to progress. If the disorder is mildly affecting appetite, behavioral therapy may be enough to make the patient eat enough to gain body mass. If the disorder is more serious, however, medical complications from malnutrition are likely to occur.
Very few high achievers become anorexic. Yet the majority of patients with AN seem to be high achievers. Perfectionism may be a predisposing trait, but should not be assumed to be the underlying problem. It is when this trait is combined with chronic disease, that there is a potential for developing an eating disorder. In an age when dieting and strenuous exercise have become so popular, one should never assume that excessive weight loss is the choice of the anorexic individual, even if they seem fixated on that goal. It is more likely a chronic medical problem that makes it very difficult for them to eat or absorb enough nutrients. Identifying and treating the underlying disorder is the key to recovery.