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Perfectionism in Past and Present Anorexia Nervosa.

The desire to starve oneself has been documented since the middle ages (Forcen & Forcen, 2015) but it was only in the second half of the 19th century that the scientific community acknowledged that certain types of volitional food restriction have a psychological origin rather than a medical one (Madden, 2004). Gull is often credited as being the first to describe this disorder and call it anorexia nervosa (Vandereycken & Van Deth, 1989). However, accounts of anorexia nervosa (AN) remained sparse through the first half of the 20th century and it was only with work from the likes of Bruch (1979) that interest in anorexia grew. Bruch's work described more specifically the psychological motivation to restrict food, arguing that the "relentless pursuit of thinness" (Bruch, 1979, p.4) is based in hunger for feelings: women who starve themselves do so to cover up a need for emotional fulfillment and love.

While intense fear of becoming fat, dangerously low weight, and dissatisfaction with body shape continue to be the defining diagnostic signs of AN (American Psychiatric Association, 2013), other features of the disorder have been identified: most significantly, a tendency towards rigidity and obsessionality (Halmi et al., 2012; Tokley & Kemps, 2007), a characteristic that has been observed in childhood prior to the development of the disorder (Wonderlich, Lilenfeld, Riso, Engel, & Mitchell, 2005). This set-shifting difficulty has led to questions about the connection between AN and obsessive-compulsive disorders. This makes sense since anorectics are obsessed with looking thin, and employ systematic and compulsive rituals to accomplish such goals. Halmi and colleagues (1991) observed significant elevations of obsessions and compulsions in individuals diagnosed with AN, and subsequent studies have confirmed such findings. Swinbourne and Touyz (2007) in their review of the literature that looks at the connection between anxiety and AN, reported on a number of studies that showed significantly high rates of comorbidity, with one study showing a 75% probability of a dual diagnosis, with OCD being the most commonly occurring type of anxiety. Furthermore, anxiety developed early in childhood (separation, phobias, overanxiousness) was found in 58% of the participants (Deep, Nagy, Weltzin, Rao, & Kaye, 1995). Although we cannot conclude that AN is a biologically-based anxiety disorder (Le Grange, 2016; Treasure, Claudino, & Zucker, 2010) this does point to the possibility that the early development of anxiety is a risk factor for developing AN.

Since OCD is the most commonly occurring type of anxiety associated with AN, we were interested in exploring what type of obsessive and compulsive behaviors are more likely to occur among anorectic patients. Srinivasagam et al. (1995) found in two separate studies that there are target OCD behaviors that are specific to anorectics, namely concern for precision, arranging, order, and symmetry. Matsunaga et al. (1999) found almost identical results, with anorectic patients having a significantly higher level of ordering/arranging and exactness compulsion (in comparison with OCD patients). Halmi et al. (2003) replicated these results, finding obsessions/compulsions in 79 % of their participants, as shown by their ordering, symmetry and, to a lesser extent, hoarding tendencies.

With factors such as exactness, rigidity and order often present in individuals with anorexia, we were interested in examining the characterological component of AN. This is because the behaviors described above fit the traits of a person with Obsessive Compulsive Personality Disorder (OCPD). Often referred to as perfectionism, OCPD is a disorder that is characterized, among other diagnostic features, by the need for control ("... is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things, American Psychological Association, DSM 5, 2013, p. 678), a disproportionate attention to responsibilities and duties ("... excessively devoted to work and productivity to the exclusion of leisure activities and friendships," DSM 5, p. 678); and an inflexibility akin to 'all or nothing' thinking ("... scrupulous, and inflexible about matters of morality, ethics, or values"; DSM 5, p.678). In addition to its matching with a number of criteria that fit the DSM 5 diagnosis for OCPD, perfectionism has been shown in a number of studies to be associated with AN (Castro-Fornieles et al., 2007; Forbush, Heatherton, & Keel, 2007; Machado, Gonsalves, Martins, Hoek, & Machado, 2014). Furthermore, Halmi et al. (2005) found specifically that the obsessive-compulsive behaviors of anorectics match OCPD traits since the most common psychological manifestations are concerns over mistakes and doubts about actions--key features of perfectionism.

Interestingly, other studies that have looked at the correlation between OCPD and anorexia have observed that obsessive compulsive traits persist after diagnostic recovery. Indeed, other studies have found that weight restored anorectics continue to be obsessed with precision and are fearful of errors (Bastiani, Rao, Weltzin, & Kaye, 1995; Nilsson, Sundbom, & Hagglof, 2008). Another study that looked at patterns in a card sorting test showed evidence of rigidity and inflexibility persisting after recovery. Specifically, Lindner, Fichter, & Quadflieg (2014) found that fully recovered anorectics exhibited more perseveration, spent less time shifting sets and developed fewer categories than the healthy control group.

To analyze the elements of perfectionism that seem to be associated with AN is one of the objectives of this study. Another aim is to explore whether such traits persist in individuals who have recovered from the disorder. We believe this is important because this will allow clinicians and care givers who are actively involved with individuals who have had a history of AN to continue being aware of such tendencies and better understand their mindset. We also believe our study will provide a contribution to the literature on perfectionism, as current scales most commonly used to measure it are lacking in a fundamental sense: they are constructed by researchers and are, as such, imposed on persons under study (Brown, 1980). Our intention is to employ a methodology that covers all possible aspects of perfectionism. It aims specifically at asking persons to categorize themselves in a manner that reflects how they truly think and feel rather than by answering questions in a piecemeal fashion, as is characteristic of questionnaire responses. In a survey using a Likert-type scale for example, participants typically circle a response as if it were independent from other survey questions when in fact all questions are connected elements of what is very often a single domain of inquiry (e.g., participants' views on the legalization of marijuana).

METHOD

Q methodology was designed specifically to understand human behavior by observing persons in their environment and, as a result, give insight into what is psychologically significant to them (McKeown & Thomas, 2013; Watts & Stenner, 2005). The methodology is designed to place the individual at the center of its inquiry: it studies the person's viewpoints, not the ones generated from a researcher's measuring instruments. Scales designed by researchers can be problematic, in our opinion, as they assume all individuals have more or less of a certain trait or motivation (e.g., low in introversion, high in openness to experience) when, in fact, it is quite possible for a person to have none of this or that (Brown, 1980). To use this study as example, perfectionism may be a trait that is non-existent in some and rejected in others with both such behaviors not accounted for in scales designed to measure degrees of perfectionism. When persons participating in a study are at the center of the investigation, they are the ones who tell us whether or not they lack a trait altogether or have much of it. In other words, they classify themselves so that the viewpoints that emerge in our inquiry are theirs.

With respect to prior use of Q methodology for studies on perfectionism, we have found none that have already been published. One study has analyzed personality organization in individuals with eating disorders, specifically looking at various personality subtypes of both anorectics and bulimics (Westen & Harnden-Fischer, 2001). However, this study has limitations, in our opinion, since it uses a scale developed by the authors (the Shedler-Westen Assessment Procedure200) and explores the topic from the perspective of the clinician - not from the viewpoint of the persons under study (i.e., a patient with bulimia or anorexia).

Participants

Participants were sixty-two women from a liberal arts college on the east coast of the United States (Table 1). They were recruited through the psychology's department online participant system. Ranging from 18 to 22-years of age, they were self-placed in three demographic categories: Women with no past or present history of anorexia; women with past anorexia; and women with present anorexia. Twenty participants categorized themselves as having a past or present history of anorexia (15 past; 5 current anorexia) and 42 participants said they had never been diagnosed with that disorder.

Procedure

The first step in Q methodology is to generate a population of statements, called a concourse (Stephenson, 1986), that reflects comprehensively the domain of inquiry. We gathered information from a variety of sources to accomplish this objective. Nine interviews were conducted with university students (five who identified themselves as perfectionists and four who did not). They were asked: 'what does perfectionism mean to you;' 'how would you define perfectionism;' and 'when do you know if someone is a perfectionist.' This constituted the natural information source and is consistent with the self-referent nature of Q methodology (McKeown & Thomas, 1988). Sources from published and audio-visual documents were also utilized to develop the concourse. We used information from academic and popular literature and various media sources in addition to already existing scales of perfectionism.

Our next step was to define the main themes or effects (Stephenson, 1950) that connect with the perfectionism construct. This was accomplished by gathering information from all sources that discuss or define the term followed by a determination, by a team of six researchers, the total amount of perfectionist-related themes. Thirty-one different elements emerged from the process with each element representing a separate aspect of perfectionism (Table 2). For example, conformity, rumination and control are some such elements as they are common words associated with perfectionism. Statements were then constructed from those themes and were replicated (so that one endorsed the value while the other did not) for a total of 62 concourse-defining statements. Statements that endorsed perfectionism include: 'I like/don't mind when spontaneous events occur in my day and I have to alter my plans' (spontaneity element) and 'I become frustrated if things are not done a certain away' (rigidity element). Statements 'against' perfectionism include: 'I enjoy fun competition where winning doesn't really matter' (competitiveness element) and 'even if I make a decision I am unsure is the right one, I let it go and deal with the possible drawbacks' (rumination element). Clarity of statements was tested using two separate focus groups. None of the statements was dropped but some were rephrased for additional transparency and to reduce the possibility of double-meaning.

After the statements representing perfectionism and participants were selected, the Q sort was administered. An initial presorting was done with participants categorizing statements into three separate piles (valuable to me; of no value to me; of contrary value to me). The actual sorting followed; instructions were: "sort the items according to their value of importance to you with a score of + 5 indicative of most value, a 0 indicative of a lack of value and a score of - 5 an indication of opposite value." Each statement was placed by the participant on a magnetic board with one statement in each of the 62 statement slots. Finally, participants were asked to explain the rationale for placing statements in the extremes (+5, +4, -4, -5).

The distribution pattern of this Q sort followed a normal distribution as is shown in Table 3. While some have objected to this 'forced' distribution (Cronbach & Glaser, 1953), Brown (1971, 1985) has shown it has no statistical or methodological significance and its purpose is to simplify data analysis. Furthermore, McKeown and Thomas (1988) noted that this structure is "in keeping with the Law of Error [because] it is assumed that fewer issues are of great importance than issues of less or no significance. Thus, fewer items are found at the extremes" (p.35).

RESULTS

Factor Extraction and Rotation

Data analysis was performed using PQMethod software (Schmolck, 2014). Factor rotation was performed using the centroid method, otherwise known as the judgmental or manual method. Both Stephenson (1961) and Brown (1980) argue that it is the most appropriate form of factor rotation as it is in line with a theory-based method of scientific investigation. Since one often begins a piece of work with a certain idea (or theory) and subsequently develops a method to investigate, rotation of factors can be performed at the discretion of the researcher. To use this study as an example, if our research question aims to show that anorexia and perfectionism are connected then factor rotation that confirms such hypothesis is warranted.

Factor Selection, Variance, and Scores

After factors were rotated, we determined how many will be used for data analysis. An often used criteria for factor selection is an eigenvalue greater than 1.00. Brown (1980) however, showed that using such a guidepost is problematic because it may result in leaving out significant factors or "producing spurious factors (p. 222)." With respect to the latter concern, he points to the real possibility of every Q sort in a data set having a very low loading and still produce an eigenvalue greater than 1.00, since an eigenvalue is a sum. (1)

Our criteria for factor inclusion was a minimum of two Q sorts having significant factor loadings. This resulted in the extraction of 3 factors (Table 4), thus differentiating three types of persons or viewpoints, each of which will be described in detail in the next section.

With respect to the variance explained by each factor, it is determined by squaring their respective eigenvalues and dividing each by the number of sorts. That number is then multiplied by 100 for percentage conversion (S. Brown, personal communication, June 21, 2018). The total variance accounted for by the three factors (i.e., the sum of their respective variance) was 46 %.

Factor A: The Adventurous and Flexible

Factor A had the most explanatory power in this study and accounted for 20% of the variance. It was endorsed by exactly half of the study's participants (31 out of 62) indicating that their responses loaded significantly on this factor. This factor was almost exclusively valued by women who did not report any past or present history of anorexia nervosa. Only one person from the thirty-one who loaded on Factor A identified as having a personal experience with anorexia; she disclosed being diagnosed by a mental health professional as having AN six months prior to their participation.

This factor's main characteristic is a viewpoint that focuses on life as adventurous and needing spontaneous elements to it. Individuals who loaded on Factor A believe variety and flexibility are necessary elements of everyday life. Also attractive is the new and unexpected. The statements below that reflect such viewpoints received high positive factor scores (indicative of high endorsement of the values they represent) and are distinguished from factors B and C:
   I love experiencing new things (+5)
   I need spontaneity to enjoy life (+4)
   I enjoy flexibility in my life and schedule (+4).


The recognition that life is unpredictable is another essential element of how Factor A loaders think. But this uncertainty about the future is not viewed as a problem per se but rather as a fact of life: human thinking and feeling is fallible and our (natural) imperfections will necessarily lead to occasional failings.
   I don't think anyone can be flawless (+5)
   I know people sometimes fail; it happens to all of us (+5)
   I am only human. I cannot accomplish everything (+4)


Not shying away from trying new things, needing variety, and the unpredictable nature of life also impacts their position on creativity. Although this value is not as strongly endorsed as the ones just discussed, it still is one that separates them from individuals who loaded on factors B and C.
   I am creative and don't mind thinking outside-of-the-box (+3)


Individuals who loaded on Factor A seem detached from any perfectionistic values. Statements that endorse a tendency to be perfect, the need to be ordered and structured are opposite to their value system and received high negative factor scores (indicative of high disagreement of the values they represent).
   I feel as though there is no room for flaws in my life (-5)
   I aspire to be perfect (-4)


Another element that seems against the viewpoints of Factor A loaders is specific attention to particular activities' preparative elements. High negative scores were given to statements that emphasize organizational aspects of everyday life and its lack of psychological impact if such goal is not accomplished.
   When getting dressed in the morning, I plan my outfit so
   specifically and, if it doesn't look perfect, I get upset (-5)
   If my routine is changed, I find it hard to adapt and get flustered
   (-3)


Factor B: The Perfectionist

Factor B explained 19% of the variance and was represented by a little over 1/3 of this study's total participants (21 out of 62). In terms of demographic characteristics, it is in sharp opposition to Factor A, as it is primarily defined by women who have a past or present history of AN. More specifically, 16 women who loaded on this factor defined themselves as such (13 with past anorexia; 3 with current anorexia) while 5 women said they never had this type of disorder.

The most prominent characteristic of this factor appears to be the focus on rumination and an uncompromising (internal) pressure to perform excellently. The extensive self-analysis and a perception that perfection is the standard leaves them with a sense of overall dissatisfaction if a target goal is not accomplished. The following distinguishing statements reflect this pattern of thinking:
   I commonly find myself overanalyzing and focusing on the
   nitty-gritty of things (+5)
   I feel as if I have to do everything perfectly (+4)
   I feel like I never do enough, even after I complete everything
   I need to (+3)
   I aspire to be perfect (+3)


Another core feature of this factor is an obsession about past action and a fear of having fallen short of expectations. More specifically, endorsers of this factor lack confidence with respects to choices made, question their overall worth, and think intensely about alternative choices that may have provided more favorable outcomes. As a consequence of such a mindset, women who loaded on this factor focus on perceived mistakes and downplay positives.
   If I make a decision I am not sure is the right one, I fester and
   obsess over how I should have behaved differently (+5)
   I often focus more on my mistakes rather than my accomplishments
   (+4) Even when I achieve something, I feel like I could have done
   more (+4)
   If I do not do well at work or school, I begin to question my
   character and worth (+3)


With both past and present decisions interpreted as failures forming a core feature of self, it may not be surprising that the statement that is most distinguishing of Factor B is one that combines both. The statement below summarizes well the overall mindset of the women who have sorted themselves in a Factor B manner:
   I constantly worry about making mistakes or think about my past
   mistakes (+5)


A common feature of persons with perfectionist tendencies is the expressed need for extensive control over various aspects of life (Eisen, Mancebo, Chiappone, Pinto, & Rasmussen, 2008; Taylor et al., 2010; von Lojewski & Abraham, 2014).This mindset drives such individuals towards rigidity and inflexibility as it diminishes their fear of losing control over outcomes. Endorsers of factors B strongly detach themselves from appreciating surprising outcomes and a life that incorporates elements of unpredictability.
   I don't always like to be in control of what's going on in my life
   (-5) I like to go with the flow and let life take me wherever (-4)


Another aspect of feeling the need to control one's environment and outcomes is to follow rules or guidelines. Order and structure are essential in that respect, and situations that lack precise guidelines are contrary to their values.
   I don't like when life is too structured or orderly (-4)
   I don't always follow rules; sometimes this can lead to problems/
   Failure but that is ok (-4)


Factor C: Routine

With 7 % of the variance explained, Factor C was endorsed by five of this study's participants. Their demographics are mixed, with three women reporting no history of AN and two women stating they had AN.

The type of individuals who have significantly loaded on this factor seem to endorse statements that encompass aspects of both factors we just discussed. Its key statements, however, focus specifically on routine and (physical) tidiness as essential values.
   My routine is very important to me (+5)
   My closet is very neat and my planner is up to date and accurate
   (+5)
   If my routine is changed, I find it hard to adapt and get flustered
   (+4)


At first look, scores for statements such as the ones above seem to indicate the same type of mindset that Factor B endorsed, namely the value of having a predictive and orderly life. However, a more careful look at the data shows us they are different in a fundamental sense: they focus on the routine aspect of order. For while the distinguishing statements for Factor B were ones that focused on the mental and emotional aspect of a fear of not being perfect (rumination, self-confidence, fear of mistakes), Factor C endorsers seem concerned with the task-oriented and habit-based aspects of 'doing things right.' This can be evidenced by the statements below showing that emotional and/or cognitive aspects of obsession are not valued.
   I try my best regarding school and work, but it doesn't consume me
   (+4) (-4)
   I do tasks to the best of my ability and then leave them as is (+4)
   (-2)


On the opposite end of the value spectrum, key Factor 3 disagreement statements focus on the need for control, but without specifications of type. The statements below show a clear discomfort with an unstructured life but don't outright indicate if disagreement is over mental, emotional or behavioral type of order.
   Change doesn't bother me; I actually embrace it (-5)
   I don't like when my life is too structured or orderly (-5)


It is only after further inquiry, by asking individuals post-q-sorting about their mindset when disagreeing with such statements, that they indicated they meant its habit-based quality. Thus, it further confirmed the need for behavioral control as a primary aspect of this factor.

Consensus Statements

With a large number of pure Q sorts (i.e., sorts that were significant on one factor only), the probability of consensus statements diminishes considerably and factor reliability is quite high (S. Brown, personal communication, May 3, 2017). This leaves little room for consensus, i.e., statement scores that do not significantly distinguish any pairs of factors. In this study however, two statements did fulfill the lack of significant difference criteria between any pair of factors at a p> .05 level. As seen below, the first listed statement has all three factor loaders having consensus against the statement while the second listed statement indicates mild endorsement.
 I often times will complete something half way   -3   -3   -4
 It really bothers me when people don't follow     1    2    1
 instructions


Not surprisingly, statements that do not reflect any of the values that define factors one, two, or three will be rejected. While it may be more visibly evident why proponents of Factor B, the Perfectionist Factor, and Factor 3, the Routine Factor do not appreciate completing 'something half way,' why would Factor A loaders, those who appreciate the adventurous and unexpected aspect of life, disapprove of it as well? That is most likely because having an adventurous spirit and enjoying spontaneity and unpredictability is different from endorsing a value system that encourages not working hard or not accomplishing tasks, as the statement about half way completion seems to imply. This explains as well why endorsers of any of the factors agree it is somewhat bothersome that instructions are not followed: It may lead to task incompletion and a job improperly done.

DISCUSSION

Are women with a past or present history of anorexia likely to be perfectionists and do they differ from women who do not have such history? This was the current study's main question as it set forth to provide supplementation to a growing amount of evidence of a link between a rigid and obsessive mindset (separate from the ritual-based nature of OCD) and anorexia nervosa. Establishing more clearly such a link is particularly important since core elements of perfectionism rigidity and obsessionality--are unaccounted for in the DSM 5 Diagnostic Criteria for AN. Using Q methodology to look at various types of responses related to values and beliefs associated with perfectionism, we distinguished three different types of individuals corresponding to three distinct factors. For Factor A, defined as the Adventurous and Flexible, we found that only one out of the twenty participants who identified themselves as having a past or present history of anorexia loaded on this factor. This unambiguous result points to the great difficulty individuals with anorexia have with change and its often unpredictable nature. Anorectics' lack of endorsement of this factor further pinpoints their fear of letting go of control-of themselves and/or their environment - another core aspect of perfectionism. This factor, however, was in line with the other group of participants, those who do not have any history with anorexia. Specifically, three quarters of participants who did not have a history of anorexia endorsed the Adventurous and Flexible factor.

With respect to Factor B, called The Perfectionist factor, women with past or present AN constituted the large majority of its factor loaders. Endorsing values of rigidity, rumination over choices, regrets over decisions made, and feeling perfection is a goal desired but never obtained, it defined with precision the mindset of a present or past anorectic. Three quarters of women who are or have been anorectic endorsed this factor. Perhaps more importantly however, is that 13 out of the 15 participants who said they had anorexia continued to exhibit significant perfectionist tendencies. This result gives further evidence that even though someone may no longer view themselves as having this mental disorder or a clinician may say they no longer have anorexia, symptoms of perfectionism remain. This reflects well the stubborn nature of AN and the likelihood it will survive the diagnostic recovery per se. With respect to the women who never had anorexia, a low percentage of them endorsed the Perfectionist factor (5 out of 42 participants in this category). This small number of loaders is likely indicative that women with no history of the disorder are not typically perfectionists.

An unexpected result, but one that makes sense nonetheless, is the emergence of a factor that contains elements of factors A and B. Factor C, defined as the Routine factor, was represented almost equally by participants with AN or without. In terms of overall values represented by proponents of this factor, we found it to be descriptive of a type of person that falls somewhere between the endorsement of an adventurous, spontaneous mindset and one that prefers mental rigidity and predictable outcomes. More specifically, the women who loaded on Factor C are appreciative of order and precision that allow habits and routines to be maintained but not as way to cope with mental distress. The Routine factor indicates that key components of perfectionism mindsets are not present (e.g., rumination, regret, fear of mistakes) yet they have the need for a very specific manner of organizing their lives. Some may view this as a lighter form of obsessive compulsive traits, but it is not something we can determine from the response patterns that emerged from individuals who loaded on this factor. However, what clearly emerges from the data is that Factor C proponents do not show obsessionality over matters of all sorts but do get flustered and upset if their routines are disrupted.

In terms of an advancement of knowledge this study offers, it is essentially in the methodology it employs rather than in the discovery of a connection between anorexia and perfectionism. Many studies have documented the link between anorexia and perfectionism (as we have reported in this paper) but none have done so by placing the person under study at the center of the inquiry, as we believe Q methodology does. Our contribution to the literature is also significant because the use of the aforementioned methodology generated an exhaustive list of values/elements related to perfectionism, and to our knowledge no such comprehensive list exists elsewhere.

The overall implication of this study is that diagnostic recovery from anorexia nervosa, as defined by a DSM 5 criteria no longer met, does not indicate a reduction or elimination of perfectionist tendencies that may impact the quality of life of such individuals. This means we need to give specific attention to perfectionism traits lingering when treating individuals who have diagnostically recovered from AN but continue to have difficulty with being flexible, remain excessively worried about errors, and struggle with rumination and regret about past actions. Practicing clinicians, probably more than other professionals in the field, need to be attuned with what their patients are saying, and allow them to express their voices that give us clue to such lingering symptoms. This was precisely what we attempted to do in this study as we gave participants control over classifying statements in a manner that best expressed their viewpoints and mindset. Of note, however, is that describing how one views oneself with clarity does not indicate whether or not individuals with anorexia consider it a problem or acknowledge it is worthy of changing aspects of their perfectionist tendencies. That ought to be the main question of a future study: how do anorectics interpret their perfectionistic tendencies - as it relates to their eating disorder - and which components, if any, are they most willing to change? This is a fundamental question because it taps into the motivational aspect of change and the obstacles that are related to it.

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Note: Table 5 is available upon request from the first author.

Bilal Mounir Ghandour, Madison Donner, Zoe Ross-Nash, Maryn Hayward, Madalyn Pinto, Tara DeAngelis

Elon University

Author info: Correspondence should be sent to: Bilal Ghandour, PhD, Assistant Professor of Psychology, Elon University Psychology Department, CB 2337, Elon, NC 27244, bghandour@elon.edu

(1) Brown uses the example of a dataset with 45 Q sorts each having a loading of .15. Since the eigenvalue is derived by squaring the loading and multiplying it by the number of sorts i.e., 45([0.15.sup.2])--the eigenvalue produced = 1.01
TABLE 1 Participant Demographics & Factor Representativeness

Variable     Mean   Mean         Factor A   Factor B   Factor C
             Age    Duration     (N=31)"    (N=21)     (N=5)
                    (in years)

Past AN      20.2   1.83 *          0         13         2
(n=15)

Current AN   20.6   4.2             1          3         0
(n=5)

No past or   19.9   --             30          5         3
current AN
(n=42)

Note. * Length of time from diagnosis to recovery

TABLE 2 Perfectionism Themes/Values & Sample Statements

Value             Statement                                For or
                                                           Against
                                                           Value

Leisure           Sometimes I like to do activities just   Against
                  for fun

Order             My closet is very neat and my planner    For
                  up to date

Conformity        I don't always follow rules; sometimes   Against
                  it leads to problems

Control           I don't always like to be in control     Against
                  of what's going on in my life

All-or-           I either consider myself successful      For
Nothing           or a failure, there is no middle
                  ground

Spontaneity       I like/don't mind when spontaneous       Against
                  events occur in my day and I have to
                  alter my plans

Rigidity          I become frustrated if things are        For
                  not done a certain way

Discipline        Sometimes I indulge in things and        Against
                  don't feel guilty

Routine           If my routine is changed, I find it      Against
                  hard to adapt and get flustered

Self-doubt        If I don't do well at work or school,    For
                  I question my character and worth

Planning          When getting dressed in the morning      For
                  I plan my outfit so specifically and,
                  if it doesn't look perfect, I get
                  upset.

Expectations      When others don't meet my standards,     For
(of others)       I am easily disappointed and annoyed

Expectations      I know that my work will have some       Against
(of self)         flaws but as long as I give it a good
                  try, I am not usually bothered by it

Productivity      If I don't do everything in the most     For
                  productive and time efficient way
                  possible,
                  I get frustrated with myself

Easy going        I feel comfortable trying new ways       Against
                  of doing things even if I fail
                  because it could be fun

Distraction       Sometimes I get off track and/or get     Against
                  distracted and it is not a big deal

Competitiveness   I enjoy fun competition where winning    Against
                  doesn't really matter

Rumination        Even if I make a decision I am unsure    Against
                  is the right one, I let it go and deal
                  with the possible drawbacks.

Perfection        I aspire to be perfect                   For

Self-Reliance     When I need help or clarity I don't      Against
                  mind asking for it

Consistency       I need my day-to-day life to be          For
                  consistent

Predictability    Sometimes I get nervous to stray from    For
                  my plan and won't try anything that
                  I do not expect to occur

Flawlessness      I am only human, I can't accomplish      Against
                  everything

Organization      I fell I must be organized all the       For
                  time

Creativity        I am creative and not afraid to          Against
                  'think outside-the-box.'

Low Novelty       Change doesn't bother me; I actually     Against
Seeking           embrace it

Procrastination   I tend of delay the completion of        For
(out of worry)    certain tasks in an effort to make
                  sure they are done 'just right.'

Comparing         Other people's performances doesn't      Against
                  greatly impact how I value my own

Mistakes          I constantly worry about making          For
                  mistakes or thing about my past
                  mistakes
Regret            Even when I achieve something, I feel    For
                  I could have done it differently

Obsessions        If I make a decision I am not sure       For
                  is the right one, I fester and obsess
                  over it

TABLE 3. Distribution Structure of the 62 Item Q Sort

LEAST VALUABLE TO ME         MOST VALUABLE TO ME

-5   -4   -3   -2   -1    0   +1   +2   +3   +4   +5

1     4    8   13   20   28   36   44   51   56   60
2     5    9   14   21   29   37   45   52   57   61
3     6   10   15   22   30   38   46   53   58   62
      7   11   16   23   31   39   47   54   59
          12   17   24   32   40   48   55
               18   25   33   41   49
               19   26   34   42   50
                    27   35   43

TABLE 4. Q Factor Correlation Matrix

Variable   Factor A   Factor B   Factor C

Factor A    1.00      -0.07       0.37
Factor B   -0.07       1.00       0.18
Factor C    0.37       0.18      1.00
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Author:Ghandour, Bilal Mounir; Donner, Madison; Ross-Nash, Zoe; Hayward, Maryn; Pinto, Madalyn; DeAngelis,
Publication:North American Journal of Psychology
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Date:Dec 1, 2018
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