Patients’ perspective of a group intervention for perfectionism in anorexia nervosa: A qualitative study

Abstract

This study aimed to explore the experiences of adults with anorexia nervosa who took part in a perfectionism group intervention in an inpatient setting. Thematic analysis was used to explore patient feedback collected in focus groups. Patient feedback was generally positive and centred around three main themes: perceived benefits of the group, the content of the group and suggested improvements. The findings suggest that a brief perfectionism group intervention is an acceptable treatment with a range of perceived benefits for patients with severe anorexia nervosa. Understanding patients’ experiences of the intervention can provide further important information to maximise therapeutic impact of the group in inpatient settings.

Keywords

anorexia nervosa group therapy inpatient treatment perfectionism qualitative study

Introduction

Anorexia nervosa (AN) is an eating disorder (ED) characterised by restriction of energy intake relative to requirements, leading to a significantly low body weight (e.g. American Psychiatric Association, 2013). It is associated with high morbidity (Treasure et al., 2010), mortality (Fichter and Quadflieg, 2016) and functional and social impairment (Harrison et al., 2014; Tchanturia et al., 2013), which highlights the need for successful evidence-based treatment interventions.

The evidence for successful treatments in AN remains limited (Hay et al., 2012), with no first-line treatment suggested (NICE, 2004). Models of AN outline the wider maintaining factors of the disorder, and it has been suggested that there is a need for treatments which address these factors (Treasure and Schmidt, 2013). High treatment drop-out rates have led to an increased focus on patients’ perspectives of different treatment models and offer unique opportunities to evaluate treatment programmes for AN from the view of the patient (e.g. Fox and Diab, 2015; Kyriacou et al., 2009; Rance et al., 2015; Smith et al., 2016). Recent qualitative studies have started to explore patients’ experiences of inpatient treatment programmes to maximise treatment benefits and improve patient experience of clinical services.

Perfectionism is a personality trait characterised by the setting of extremely high and demanding performance standards, which a perfectionist individual strives for and bases their self-evaluation upon (Frost et al., 1990). While it has been implicated as both a risk and maintaining factor across a range of psychiatric disorders, systematic reviews provide evidence that perfectionism is not only elevated in AN, but elevated in relation to other psychiatric disorders (Bardone-Cone et al., 2007; Egan et al., 2011). High levels of perfectionism have been found consistently across subtypes of AN, with no differences between those with AN binge/purge (AN-BP), AN restrictive (AN-R) and atypical AN subtypes (Garner et al., 1993; Halmi et al., 2000; Tachikawa et al., 2004), with the exception of one study which found higher perfectionism among those with AN-BP compared with AN-R (Bizeul et al., 2003). Disordered eating has also found to be associated with perfectionism in non-clinical samples (Bento et al., 2010). This finding has been supported by behavioural genetics, in which twin studies have identified a shared source of genetic and environmental risk factors for disordered eating and perfectionism (Wade and Bulik, 2007). Such findings have led to perfectionism being proposed as a risk factor for AN and a target for interventions in AN (Egan et al., 2011). In addition, perfectionism has been found to impact treatment outcome, being predictive of poorer treatment prognosis and higher treatment attrition rate (Bizeul et al., 2001; Keski-Rahkonen et al., 2014; Sutandar-Pinnock et al., 2003).

Recently, there has been increased interest in interventions targeting perfectionism. In a systematic review and meta-analysis exploring the efficacy of psychological interventions to reduce perfectionism, Lloyd et al. (2014b) concluded that it is possible to significantly reduce aspects of perfectionism using a cognitive behavioural approach in adults in whom perfectionism is the primary problem or in addition to a psychiatric diagnosis. In addition, it was found that such interventions were associated with decreases in anxiety and depression. However, despite the strong link between disordered eating and perfectionism, few studies to date (Goldstein et al., 2014; Lloyd et al., 2014a; Steele and Wade, 2008) have investigated the effect of focused interventions to reduce perfectionism in EDs. In addition, there is a lack of studies exploring the views and experiences of patients regarding perfectionism-focused interventions.

In an randomised controlled trial, Goldstein et al. (2014) investigated the effectiveness of treatment of perfectionism in a mixed ED sample, with patients assigned to treatment as usual (TAU) or TAU combined with cognitive behavioural therapy (CBT) for perfectionism. However, no significant differences were found between the treatment conditions on EDs symptoms or perfectionism. In another randomised controlled trial, Steele and Wade (2008) investigated the effect of CBT for perfectionism in a guided self-help format compared with CBT for bulimia nervosa (BN) and placebo treatment. Significant changes with a large effect size (within group effect size of 1.0) were observed for ‘concern over mistakes’ in a follow-up, 6 months after completion of the intervention. No significant changes in perfectionism were observed in the other treatment conditions. All groups reported significant reductions in bulimic symptomatology post treatment, suggesting that targeting perfectionism alone may also lead to successful reduction in ED symptomology.

Lloyd et al. (2014b) and Tchanturia et al. (2016) are the only studies to date explicitly targeting perfectionism in individuals with AN. Patients received 6 weekly sessions of a cognitive behavioural group intervention targeting perfectionism in an inpatient setting. Significant changes were observed in studies for overall perfectionism (d = 0.3–0.5), concern over mistakes (d = 0.3–0.5) and personal standards dimensions of perfectionism (d = 0.3–0.7) following participation in the group. Thematic analysis was carried out with the responses to three open-ended questions on feedback questionnaires. The minimal qualitative feedback indicated that participants appreciated the group setting by being able to learn from others and gained an insight into and awareness of perfectionism.

There is therefore evidence that it is possible to significantly reduce perfectionism in AN, which is promising given the implication of perfectionism in the disorder. Furthermore, there is some support that perfectionism interventions have an impact upon wider ED symptoms (Steele and Wade, 2008).

While Lloyd et al. (2014b) demonstrated meaningful reduction in perfectionism following the group intervention, the in-depth experiences and views of the group participants were not fully explored. As low motivation and treatment attrition rates are common issues in AN (Dejong et al., 2012; Vansteenkiste et al., 2005), patient involvement in qualitative research is valuable in the development of new treatments in EDs (e.g. Kyriacou et al., 2009; Smith et al., 2016). By exploring the participants’ views of newly developed interventions, we are able to make improvements and increase engagement and treatment success (Thornicroft and Tansella, 2011). Therefore, the aim of this study was to explore in depth, the perceived benefits of and potential improvements to the group intervention through analysis of focus groups conducted with individuals who had participated in a perfectionism group intervention.

Methods

Participants

14 participants took part in this study. Participants were recruited from the perfectionism group running at an inpatient specialist national ED service. There were no specific inclusion/exclusion criteria as the participants were recruited from a clinical programme. All participants in the study were female and had a Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) diagnosis of AN when admitted. Participants received other clinical input during the treatment, including medical, nutritional, individual therapy and attended other psychology groups. Ethical approval for the study was granted by the local Research Ethics Committee (12/LO/2013).

Procedure

The intervention

The overall aim of the perfectionism group was to increase awareness of perfectionism and to identify and challenge perfectionist behaviours and perfectionist thinking (Lloyd et al., 2014a). The group also focused on encouraging patients to adapt excessively high standards and replace these with more appropriate standards that are manageable and achievable. The protocol used for this intervention is a revised protocol from the Lloyd et al. (2014b) paper and described in Tchanturia et al. (2016) study. The distinctiveness and novelty of the current group is the interactive and experiential components included in all sessions, ranging from games and creative activities to role-plays and mind-maps, which lead to active discussion.

The group was delivered by two facilitators, one of whom was a counselling or clinical psychologist. Groups ranged in size with a mean of five participants attending per session. The intervention consisted of six sessions, and all sessions included the following elements: psychoeducation, practical exercises and games, reflection and discussion, and planning of homework tasks and challenges to try outside the group.

The topics of the sessions were (1) ‘What is perfectionism? Advantages and disadvantages of perfectionism’, (2) ‘How did I become a perfectionist and what makes up perfectionism?’, (3) ‘Managing perfectionism, adapting/adjusting perfectionist behaviours’, (4) ‘Challenging perfectionist thinking and adjusting unhelpful rules and assumptions’, and (5) ‘Re-evaluation of the importance of achievement’. The last session involved a review of the group and a creative activity through which participants reflected on what they had learned. Weekly homework was set, for example, asking participants to monitor their perfectionism and trying to notice the costs and benefits of their perfectionism (Session 1) and putting into practice a series of steps, planned in session to reduce perfectionist behaviours (Session 3 onwards).

Focus group

Data presented are for four consecutive runs of the group, which ran throughout 2015. After completion of the group programme, all participants were invited to take part in a focus group to provide feedback and ideas on how to improve and develop the intervention further. All focus groups were conducted by one of the authors (E.L., S.L. or K.T.) and were audio recorded, with participants’ permission.

Focus groups were conducted using the following interview schedule:

In what ways was the group useful? What did you like about the group?

Any particular aspects you found useful?

What will you take away from the group?

What do you feel we could do to improve the group?

Anything else you want to tell us about the group?

Analysis of transcripts

Transcripts were typed verbatim. Thematic analysis as described by Braun and Clarke (2006) was used to analyse the transcripts and to identify themes. Due to the focus group being based on specific questions, the analysis was used to evaluate participants’ opinion of the psychology group and to gain a deeper understanding of their thoughts and experiences.

One of the authors, E.L., explored the transcripts in depth and coded for categories. If a category was mentioned more than once, this was then made into a broader theme. Totally, 75 per cent of the transcripts were explored by a second researcher (S.L.), with good consensus found between the two researchers and themes discussed and developed accordingly. The preliminary themes were continuously reviewed and revised in order to reduce and synthesise the categories into the most important and representative themes.

Results

Patient characteristics

The mean age of the participants was 27.4 (SD = 7.7), with a mean illness duration of 11.5 years (SD = 7.2). The mean body mass index (BMI) at the first session was 15.3 (SD = 2.6). Totally, 64 per cent of the patients were diagnosed with restrictive AN, 21 per cent with AN-BP, and the remaining participants were diagnosed with atypical AN. Patient characteristics are displayed in Table 1.

Table 1.

Participant characteristics.

Focus group	Participant ID	Age	BMI	Duration of illness (years)	Diagnosis
1	Participant 1	33	19.34	19	A-AN
1	Participant 2	45	19.20	24	A-AN
2	Participant 3	23	14.35	13	AN/R
	Participant 4	23	15.24	7	AN/R
	Participant 5	23	17.65	10	AN/BP
	Participant 6	35	16.89	16	AN/R
	Participant 7	22	15.48	9	AN/R
	Participant 8	32	13.41	17	AN/R
3	Participant 9	19	14.18	4	AN/R
3	Participant 10	21	14.39	2	AN/R
4	Participant 11	34	13.05	22	AN-BP
	Participant 12	33	13.30	12	AN-BP
	Participant 13	20	13.16	5	AN/R
	Participant 14	21	12.24	2	AN/R

A-AN: atypical anorexia nervosa; AN/R: restrictive anorexia nervosa; AN-BP: anorexia nervosa binge/purge; BMI: body mass index.

Thematic analysis

The relevant themes and sub-themes identified from the focus groups are outlined in Table 2. Frequencies of key themes are given to help illustrate patterns within the data and support transparency of data analysis. However, the strength of each theme is related to the importance placed on it within the focus groups, not merely on the prevalence.

Table 2.

Themes and sub-themes from focus groups.

Perceived benefits	Benefits of the group setting Sharing experiences and learning from others Awareness of similarities and differences in experiences of perfectionism Extension beyond sessions Challenges of the group setting Awareness and self-reflection Awareness of perfectionism Recognising the negative impact of perfectionism Excellence versus perfectionism Bigger picture thinking
Nature of the group	Practical/interactive nature of the group Application outside of the group: homework
Suggested improvements	Increased number of sessions Further support in application and setting of goals Focus on additional areas

Perceived benefits of the group

Overall, the group was seen as being informative, with 12 of the 14 participants (86%) describing having found the content of the group useful and having discovered something new:

I was kind of having little kind of light bulb moments, thinking ‘oh yes I haven’t thought about that before’ that I’ve not kind of got from the group before. (Participant 1)

The perceived benefits of the group fell into two main sub-themes: benefits of the group setting and awareness and self-reflection.

Benefits of the group setting

Nine participants (64%) reflected directly on the benefits of the group setting, suggesting specific benefits associated with this:

You know if I read things … I don’t think oh right so now that I know this and understand it, how is it going to change the way I behave, but having a group and talking about the ideas of how you can change is different to reading a book. (Participant 1)

Sharing experiences and learning from others

Five group members (36%) discussed the importance of sharing experiences and learning from each other, as well as feeling reassured by hearing the experiences of others:

Other people kind of like reassured us and said we have it too, you are not alone in this … It generated almost a kind of feeling of community in the group as well. (Participant 14)

Similarities and differences in the experience of perfectionism

Out of 14 participants, 5 (36%) spoke specifically about the group setting being helpful through highlighting perfectionist behaviours. A number of individuals discussed this in terms of gaining awareness of the fact that perfectionist behaviours can vary widely between individuals:

… It was good to see that everyone wanted to be perfect in different ways … You always think you are the only person, so it was nice to see that there were other people that felt the same. (Participant 12)

Extension beyond sessions

Some participant accounts (21%) suggested that the benefits of the group setting extended beyond the group, with some members continuing to discuss perfectionism outside the group and support each other:

We’ve been able to challenge each other outside of the group and kind of make it into a bit of a joke sometimes. (Participant 1)

Challenges of the group setting

While the experience of group members in relation to the group format of the intervention was, on the whole, positive, some members discussed negative aspects or challenges of the group setting. Two members (14%) also spoke about it sometimes being difficult or unhelpful to hear others’ experiences and opinions:

… (the group setting) sometimes useful, sometimes kind of toxic. Like things you hadn’t considered or like didn’t want to consider, having to listen to them and sometimes I don’t think it’s very helpful. (Participant 10)

Awareness and self-reflection

The majority of the patients (13 out of 14 participants; 93%) mentioned some form of self-reflection arising from the group, acknowledging that the group has helped them become more aware of their perfectionist behaviours, recognising the impact of their perfectionism or being able to ‘zoom out’ and see the bigger picture.

Awareness of perfectionism

A common theme emerging in all focus groups was that the group engendered a better awareness of perfectionism in terms of what perfectionism is and its associated behaviours and thoughts. Nine group members (64%) discussed this as being a way in which they had benefitted from the group. Within this theme, three participants (21%) highlighted certain behaviours, including procrastination, which they had not previously identified as being perfectionist:

To be able to talk about procrastination in terms of worrying so much about being able to do something perfectly that you just keep putting it off … I’ve never made that link before, so I found that really useful. (Participant 1)

Recognising the negative impact of perfectionism

Four participants (29%) described how the group had enabled them to recognise the negative impact of perfectionism. The participants described becoming aware of the detrimental impact perfectionism has upon their lives:

I could not submit one assignment because they weren’t perfect and they were too long. And that’s quite a big thing. (Participant 6)

Excellence versus perfectionism

Four participants (29%) highlighted the usefulness of making contrasts between positive and negative aspects of perfectionism and making a distinction between perfectionism and excellence:

… I hadn’t really considered it in that much detail before, and how kind of like detrimental perfectionism can be for a person, versus excellence, which seems a bit more optimistic. (Participant 14)

Bigger picture thinking

Out of 14, 3 (21%) participants discussed how the perfectionism group helped them develop an ability to see the bigger picture in the context of their perfectionism:

… Now I can kind of take a step back and say it’s a tiny detail and it doesn’t really affect my entire life … You can just be content with the overall picture. (Participant 3)

Nature/content of the group

In addition to benefits perceived in relation to the group setting and learning about perfectionism, participants discussed what it was about the format of the group which was helpful.

Emphasis on practical and interactive activities

Several patients mentioned finding the practical activities beneficial. The majority of group members (93%) discussed enjoying and benefitting from the interactive tasks within the sessions. Several members discussed the way in which the tasks were engaging and enjoyable to take part in:

… The whole interactive, practical side of doing things was really helpful. It’s really boring when you’re sitting in a group and there’s just talking. But we actually played games…it meant that you were able to kind of completely immerse yourself in the group. (Participant 7)

Members described the way in which tasks highlighted perfectionist behaviours and thinking, which they could then work upon in the group. The practical activities and tasks appeared to work as a stimulus to further discussion of what group members’ experienced while carrying out the tasks:

Instead of switching yourself off, it can give you that initial reaction like oh so how does it feel to be able to do that…it’s an emotion that you can’t actually bring up unless you are in the situation. (Participant 5)

Application outside of the group

Four group members (29%) discussed the benefit of applying what they had learned in the sessions to their everyday life outside of the group and the inpatient setting. Going beyond the group each week was something which was seen as important in challenging perfectionism:

Not just kind of a session that was self-contained, it was something that carried over and that I continued like reading into and stuff. (Participant 14)

Suggested improvements

Increased number of sessions

Half of the participants said that they would have liked to have more sessions of the group:

… I think it will take longer than 6 weeks, because it does help but it stops and its going back to the normal life sort of thing, so I think, more sessions will help you get back into not trying to be perfect all the time. (Participant 12)

Two participants (14%) suggested different kinds of follow-up to further the support from the group and aid application:

Maybe it doesn’t even need to be physically meeting in a room, maybe it could be you know, everyone uses the internet, maybe it could be set up even as a forum discussion. (Participant 1)

Further support in application and setting of goals

An important suggested improvement was participants having further support in applying what they had learned in the sessions. Six (43%) participants asked for a stronger focus on application to real life. One theme, which was identified in two of the focus groups (6 out of 14 participants; 43%), was group members wanting further support in challenging their perfectionism using activities outside of the group. In general, individuals wanted more tasks and challenges and support in what to choose in terms of their own personal goals:

… I think we needed more time on the steps, breaking it down. And I think maybe …if we talked about it in a group, it might have happened more. (Participant 9)

Focus on additional areas

Two participants (14%) suggested that additional focus on maintenance factors of perfectionism would have been beneficial to be able to aid the changes in real life:

Thinking about the maintenance and what actually maintains that would make us keep doing it and what actually drives us to do things would be really helpful. (Participant 6)

The participants of Focus group 2 (29%) highlighted that for them, it would have been helpful to discuss the links between perfectionism and their illness:

I think maybe if you can link it to anorexia a bit more, I’m working to a perfect body shape you know, or the whole my body’s not perfect so I can’t carry on … focusing completely on anorexia would be helpful. (Participant 7)

Discussion

This study explored participants’ experiences of a short group-based perfectionism intervention. Thematic analysis of data from four focus groups identified three main themes: perceived benefits, the nature of the group and suggested improvements and divided into a number of sub-themes.

On the whole, participants expressed having benefitted from the programme, broadly as a result of the group nature of the intervention and as a result of the group engendering awareness of perfectionism and self-reflection. The majority of patients expressed finding it useful to share experiences, being able to learn from others and to gain an awareness of similarities and differences in the experience of perfectionism. It was also evident that the impact of the group setting extended beyond the group; participants seemed to encourage each other outside the group and continue some of the discussions around perfectionism. The interactive nature of the group was felt to be important, as well as the opportunity to apply what was learned in the group outside of the sessions through homework tasks. This is in line with previous qualitative studies (e.g. Smith et al., 2016), where patients have highlighted that they valued the shared understanding with their peers. This supports the finding that delivering psychological interventions in a group format can bring unique benefits that are not achievable when working with patients individually (Tchanturia and Sparrow, 2015).

The findings build upon our previous work, as well as wider research (for a review, see Lloyd et al., 2014b), which has found perfectionism group interventions to be associated with significant reductions in perfectionism (Lloyd et al., 2014b; Tchanturia et al., 2016) and targeting perfectionism to be associated with wider changes in ED symptoms (Steele and Wade, 2008). It is also in line with existing literature which has found group interventions for EDs to be associated with numerous benefits including increased opportunities for interpersonal growth and learning and insight into the self and cohesion (Moreno, 1994; Sparrow and Tchanturia, 2016; Tchanturia and Sparrow, 2015). The finding that the group setting was regarded as helpful is important given that individuals with AN often experience difficulties making social contacts (Doris et al., 2014; Tchanturia, 2015a; Tchanturia et al., 2013) and report high levels of social anhedonia: an absence of pleasure derived from being with people (Harrison et al., 2014; Tchanturia et al., 2012).

The group was considered to engender a better awareness of perfectionism in terms of what perfectionism is and associated behaviours and thoughts. Participants also described how the group had enabled them to recognise the negative impact of perfectionism, as well as gaining awareness of perfectionist behaviours and developing an ability to see the ‘bigger picture’.

The finding that the group was perceived to be associated with improved awareness and opportunities for self-reflection was in line with the aims and focus of the group. The focus upon both positive and negative aspects of perfectionism is interesting given the evidence for the ego-syntonic nature of perfectionism, with qualitative research having found that individuals with perfectionism identify benefits of their perfectionism (Egan et al., 2013). Participants perceived the group to be associated with changes in bigger picture thinking, in line with other studies which have found perfectionism interventions to be associated with wider benefits in terms of cognitive style. Hurst and Zimmer-Gembeck (2015) found that an intervention targeting perfectionism was associated with decreased rigidity, suggesting that this may be associated with an increased ability to view making mistakes as an opportunity for learning, as opposed to being perceived as failure. It is also encouraging given that it has been suggested that increased detail focus, as opposed to bigger picture thinking, is associated with perfectionism and concern over mistakes (Lang et al., 2014).

Suggested improvements by participants were an increased number of sessions, focus on maintenance factors and upon the association between perfectionism and AN and increased support in applying the learning from the group outside of sessions and in developing appropriate goals. Increased support in this area may be an important focus for future interventions given that it has been suggested that the all-or-nothing thinking style and perceived failures associated with perfectionism may make the setting of appropriate treatment goals difficult (Goldner et al., 2002).

This study aimed to explore participants’ perceptions of taking part in a perfectionism group intervention and their suggestions for improvements. It added to the current literature by including more in-depth exploration of participants’ experiences of participating in a perfectionism intervention. This study is the first to date to evaluate the use of a perfectionism group intervention qualitatively. The analysis of patients’ feedback was conducted systematically and rigorously using thematic analysis, with strong consensus between two researchers (E.L. and S.L.) concerning themes. Patients’ feedback reported here will inform future studies in terms of patients’ needs and ideas to develop the group further. In general, this study adds to the limited qualitative literature in AN in how to improve treatment and address issues outside of the specific ED symptoms (eating, body shape and weight).

Several limitations warrant discussion. First, not all participants took part in the focus groups. Participants chose whether to take part, and it is possible that those self-selecting to take part in the focus groups may have had been those who were more actively involved in the intervention, more motivated or had more positive experiences. Second, it is important to note that all patients who took part in the perfectionism groups were in specialist inpatient care, and findings may not be generalisable to other settings.

One of the main weaknesses of this study is the small sample size, as despite data coming from several focus groups, only 14 participants participated. While smaller sample sizes are commonplace in qualitative work, several of the themes came from limited data, therefore, the findings may not represent the wider views of AN patients residing in inpatient setting. The interview schedule used in this study was also structured, and may therefore not have allowed for the elaboration of spontaneous views of the participants. While the aim of this study was to identify specific views on the usefulness of the group, further work may benefit from taking a more inductive approach with a larger sample size. While qualitative studies provide unique insight into the views and experiences of individuals, they cannot be used to evaluate the efficacy of complex interventions, and thus quantitative work assessing the benefit of the perfectionism intervention in targeting both ED and wider pathology are ongoing (Tchanturia et al., 2016). Future studies should also investigate the perceived impact of such interventions upon ED symptoms.

Clinical implications

This study provides support that a brief perfectionism intervention is perceived as helpful by AN patients with a severe and long duration of the illness. This is a key finding as treatment resistance and poor motivation are common challenges in AN (Vansteenkiste et al., 2005). While this study is unable to determine the efficacy of a perfectionism intervention in AN, the finding that the group was perceived positively by patients is promising and increases feasibility of evaluating the group intervention using quantitative methods.

A group format is a valuable tool in EDs (Moreno, 1994; Tchanturia and Sparrow, 2015); it is a cost and time-effective option for treatment and has previously presented similar results as individual therapies (Ohmann et al., 2013). These findings add to previous quantitative studies, in which perfectionism group intervention have been found to be effective in reducing perfectionism in participants with an axis one diagnoses (Steele et al., 2013) and individuals with AN (Lloyd et al., 2014b).

Finally, it is important to note that our clinical programme also provides cognitive remediation training (CRT) in both individual and group work (Tchanturia, 2015b; Tchanturia et al., 2016; Tchanturia and Doris, 2015). This seemed to have a positive effect on the perfectionism group intervention, as patients were able to translate their knowledge about their cognitive style into the perfectionism domain. We have found it useful to run the group concurrently at the inpatient ward, as it seemed to have aided the process and reinforced the messages of the groups, which was also mentioned by patients in one of the focus groups. At this stage, the perceived benefit of running CRT and perfectionism groups concurrently is purely observational. Future studies would benefit from utilising a randomised controlled trial design in order to determine the unique or combined effects of both perfectionism and CRT interventions.

In conclusion, the perfectionism group was perceived positively by patients, who reported benefits in terms of the group setting and increased awareness of perfectionism and opportunities for self-reflection. The interactive nature of the intervention and support in applying the content outside of sessions were considered important aspects of the group.

Footnotes

Acknowledgements

We would like to thank Staff and patients in the Eating disorder Service in South London and Maudsley NHS foundation, special thanks to Dana Myers and Dr Nikola Kern. S.L. and K.T. would like to acknowledge support from a Medical Research Council/Institute of Psychiatry, Psychology and Neuroscience Excellence PhD studentship and Swiss Anorexia Foundation for financial assistance. E.L. and S.L. are shared first authors.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Swiss Anorexia Foundation (36-14; 2015).

References

American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (5th edn). Washington, DC: Available at: http://www.dsm5.org/Pages/Default.aspx (accessed 10 February 2015).

Bardone-Cone

Wonderlich

Frost

. (2007) Perfectionism and eating disorders: Current status and future directions. Clinical Psychology Review 27(3): 384–405.

Bento

Pereira

Maia

. (2010) Perfectionism and eating behaviour in Portuguese adolescents. European Eating Disorders Review 18(4): 328–337.

Bizeul

Brun

Rigaud

(2003) Depression influences the EDI scores in anorexia nervosa patients. European Psychiatry 18: 119−123.

Bizeul

Sadowsky

Rigaud

(2001) The prognostic value of initial EDI scores in anorexia nervosa patients: A prospective follow-up study of 5–10 years. European Psychiatry 16(4): 232–238.

Braun

Clarke

(2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3(2): 77–101.

Dejong

Broadbent

Schmidt

(2012) A systematic review of dropout from treatment in outpatients with anorexia nervosa. International Journal of Eating Disorders 45(5): 635–647.

Doris

Westwood

Mandy

. (2014) A qualitative study of friendship in patients with anorexia nervosa and possible autism spectrum disorder. Psychology 5: 1338–1349.

Egan

Piek

Dyck

. (2013) A clinical investigation of motivation to change standards and cognitions about failure in perfectionism. Behavioural and Cognitive Psychotherapy 41(5): 565–578.

10.

Egan

Wade

Shafran

(2011) Perfectionism as a transdiagnostic process: A clinical review. Clinical Psychology Review 31(2): 203–212.

11.

Fichter

Quadflieg

(2016) Mortality in eating disorders – Results of a large prospective clinical longitudinal study. International Journal of Eating Disorders 49(4): 391–401.

12.

Fox

Diab

(2015) An exploration of the perceptions and experiences of living with chronic anorexia nervosa (cAN) whilst an inpatient on an eating disorders unit (EDU): An interpretative phenomenological analysis (IPA) study. Journal of Health Psychology 20(1): 27–36.

13.

Frost

Marten

Lahart

. (1990) The dimensions of perfectionism. Cognitive Therapy and Research 14(5): 449–468.

14.

Garner

Rosen

(1993) Anorexia nervosa ‘restricters’ who purge: Implications for subtyping anorexia nervosa. International Journal of Eating Disorders 13: 171–185.

15.

Goldner

Cockell

Srikameswaran

(2002) Perfectionism and eating disorders. In: Flett

Hewitt

(eds) Perfectionism: Theory, Research, and Treatment. Washington, DC: American Psychological Association, pp 319-340.

16.

Goldstein

Peters

Thornton

. (2014) The treatment of perfectionism within the eating disorders: A pilot study. European Eating Disorders Review 22(3): 217–221.

17.

Halmi

Sunday

Strober

. (2000) Perfectionism in anorexia nervosa: Variation by clinical subtype, obsessionality, and pathological eating behavior. American Journal of Psychiatry 157: 1799–1805.

18.

Harrison

Mountford

Tchanturia

(2014) Social anhedonia and work and social functioning in the acute and recovered phases of eating disorders. Psychiatry Research 218(1–2): 187–194.

19.

Hay

Touyz

Sud

(2012) Treatment for severe and enduring anorexia nervosa: A review. Australian and New Zealand Journal of Psychiatry 46(12): 1136–1144.

20.

Hurst

Zimmer-Gembeck

(2015) Focus on perfectionism in female adolescent anorexia nervosa. International Journal of Eating Disorders 48(7): 936–941.

21.

Keski-Rahkonen

Raevuori

Bulik

. (2014) Factors associated with recovery from anorexia nervosa: A population-based study. International Journal of Eating Disorders 47(2): 117–123.

22.

Kyriacou

Easter

Tchanturia

(2009) Comparing views of patients, parents, and clinicians on emotions in anorexia: A qualitative study. Journal of Health Psychology 14(7): 843–854.

23.

Lang

Lopez

Stahl

. (2014) Central coherence in eating disorders: An updated systematic review and meta-analysis. World Journal of Biological Psychiatry 15(8): 586–598.

24.

Lloyd

Fleming

Schmidt

. (2014a) Targeting perfectionism in anorexia nervosa using a group-based cognitive behavioural approach: A pilot study. European Eating Disorders Review 22(5): 366–372.

25.

Lloyd

Schmidt

Khondoker

. (2014b) Can psychological interventions reduce perfectionism? A systematic review and meta-analysis. Behavioural and Cognitive Psychotherapy 43(6): 705–731.

26.

Moreno

(1994) Group treatment for eating disorders. In: Fuhriman

Burlingame

(eds) Handbook of Group Psychotherapy: An Empirical and Clinical Synthesis. New York: John Wiley & Sons, pp. 416–457.

27.

NICE (2004) Eating disorders: Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders. NICE Clinic, NICE. Available at: https://www.nice.org.uk/guidance/cg9 (accessed 10 February 2015).

28.

Ohmann

Popow

Wurzer

. (2013) Emotional aspects of anorexia nervosa: Results of prospective naturalistic cognitive behavioral group therapy. Neuropsychiatrie 27(3): 119–128.

29.

Rance

Moller

Clarke

(2015) Eating disorders are not about food, they’re about life: Client perspectives on anorexia nervosa treatment. Journal of Health Psychology 22(5): 582–594.

30.

Smith

Chouliara

Morris

. (2016) The experience of specialist inpatient treatment for anorexia nervosa: A qualitative study from adult patients’ perspectives. Journal of Health Psychology 21(1): 16–27.

31.

Sparrow

Tchanturia

(2016) Inpatient brief group therapy for anorexia nervosa: Patient experience. International Journal of Group Psychotherapy 66(3): 431–442.

32.

Steele

Wade

(2008) A randomised trial investigating guided self-help to reduce perfectionism and its impact on bulimia nervosa: A pilot study. Behaviour Research and Therapy 46(12): 1316–1323.

33.

Steele

Waite

Egan

. (2013) Psycho-education and group cognitive-behavioural therapy for clinical perfectionism: A case-series evaluation. Behavioural and Cognitive Psychotherapy 41(2): 129–143.

34.

Sutandar-Pinnock

Blake Woodside

Carter

. (2003) Perfectionism in anorexia nervosa: A 6-24-month follow-up study. International Journal of Eating Disorders 33(2): 225–229.

35.

Tachikawa

Yamaguchi

Hatanaka

. (2004) The Eating Disorder Inventory-2 in Japanese clinical and non-clinical samples: Psychometric properties and cross-cultural implications. Eating and Weight Disorders 9: 107–113.

36.

Tchanturia

(ed.) (2015a) Brief Group Psychotherapy for Eating Disorders: Inpatient Protocols. Hove: Routledge.

37.

Tchanturia

(ed.) (2015b) Cognitive Remediation Therapy (CRT) for Eating and Weight Disorders. Hove: Routledge.

38.

Tchanturia

Doris

(2015) Flexibility workshops – cognitive remediation therapy (CRT) in group format: Adults. In: Tchanturia

(ed.) Brief Group Psychotherapy for Eating Disorders: Inpatient Protocols. Hove: Routledge, pp. 25–50.

39.

Tchanturia

Sparrow

(2015) An introduction to brief group psychotherapy in intensive care programmes for eating disorders: Gathering research evidence. In: Brief Group Psychotherapy for Eating Disorders: Inpatient Protocols. Hove: Routledge, pp. 1–23.

40.

Tchanturia

Davies

Harrison

. (2012) Altered social hedonic processing in eating disorders. International Journal of Eating Disorders 45(8): 962–969.

41.

Tchanturia

Hambrook

Curtis

. (2013) Work and social adjustment in patients with anorexia nervosa. Comprehensive Psychiatry 54(1): 41–45.

42.

Tchanturia

Larsson

Brown

(2016) Benefits of group cognitive remediation therapy in anorexia nervosa: Case series. Neuropsychiatrie 30: 42–49.

43.

Tchanturia

Larsson

Adamson

(2016) Brief group intervention targeting perfectionism in adults with anorexia nervosa: Empirically informed protocol. European Eating Disorders Review 24(6): 489–493.

44.

Thornicroft

Tansella

(2011) Growing recognition of the importance of service user involvement in mental health service planning and evaluation. Epidemiologia e Psichiatria Sociale 14(1): 1–3.

45.

Treasure

Schmidt

(2013) The cognitive-interpersonal maintenance model of anorexia nervosa revisited: A summary of the evidence for cognitive, socio-emotional and interpersonal predisposing and perpetuating factors. Journal of Eating Disorders 1(1): 13.

46.

Treasure

Claudino

Zucker

(2010) Eating disorders. Lancet 375(9714): 583–593.

47.

Vansteenkiste

Soenens

Vandereycken

(2005) Motivation to change in eating disorder patients: A conceptual clarification on the basis of self-determination theory. International Journal of Eating Disorders 37(3): 207–219.

48.

Wade

Bulik

(2007) Shared genetic and environmental risk factors between undue influence of body shape and weight on self-evaluation and dimensions of perfectionism. Psychological Medicine 37(5): 635–644.