Copyright 1997, University of Toronto: School of Physical and Health Education

Introduction

This paper will examine the current literature as it pertains to aspects of perfectionism in athletes with eating disorders. The intention is to establish a contemporary theoretical base, with which to raise some informal speculation (personal theories on the subject) and suggest practical applications to deal with the problems of anorexia and bulimia nervosa among athletes.

Theories of Perfectionism

Normal vs. Neurotic

One of the most notable authors in the literature on perfectionism, D.E. Hamachek (1978), explains how individuals who originate from environments of "conditional positive approval" learn that if they are to be loved, they cannot afford to be less than perfect (29). Therefore, their "sense of self" is defined primarily in terms of performance standards. For some athletes, this strain of theory is especially poignant; the performance defines their public image and how well the audience responds to them. For athletes like Tara Lipinski, or American, Olympic, and world champion gymnast, Dominique Moceanu, performance defines them respectively, as cherished American "sweethearts" in sport. This kind of "indirect" affection between spectator and performer also generates some intriguing questions, one of which is, how do athletes at such vulnerable ages of 14, 15 or 16 deal with the conceivable possibility of disappointing their fans? If a performance, for any given reason, is not up to par with the athlete's established standards, the sporting public's fickle endearments can be easily swayed and granted to someone else. The athlete, who might very well be trained in the physical sense, such that she can perform extraordinary feats on command, is not necessarily trained in the experiential, emotional or psychological sense, such that she is capable of handling the pressures of public expectation, failure, and their own media portrayal. This issue is further exacerbated by the increasing trend of younger athletes competing at elite, international levels.

Hamachek's theory of defining one's sense of self through performance standards, pertains well to the aspects commonly associated with neurotic perfectionism. The neurotic perfectionist will generally embody a combination of traits: dichotomous (all-or-nothing) thinking, the setting of unreasonable standards, the compulsive reaching toward impossible goals, and the questioning of self-worth with productivity and accomplishment (Adderholdt-Elliot, 1991; Mitzman et al., 1994). Clearly, the terminology is vague with respect to its methodological validity (i.e., how does one categorically define "unreasonable," "compulsive," and "impossible" in these instances?); however, clarification, in using explicit examples when referring to these distinctions, is helpful in this regard.

The error in lumping together all athletes as a collective group in the perfectionism literature, is that they tend to be mass-represented as positive, "normal" perfectionists, likely because of the positive attributes affiliated with sport in general (Terry-Short, et al., 1995). Within the context of training for a particular event, or activity, athletes may have more of an opportunity to "hide" behind the positive stereotype of their preconceived role, while still behaving in destructive and unhealthy ways. One need only examine the growing literature on eating disorders or substance abuse to realize that athletes from a multitude of sports are not embodying, typifying, or living the healthy, "cereal-box," picture-perfect lifestyles which are expected of them, en masse (Davis, et al., 1994; Blouin and Goldfield, 1995; Anderson, et al., 1995). The dangers of this combination of ideal "healthy role models" and the actual dysfunctional behaviour among some athletes, are multifarious and interrelated. First and foremost, there is the risk of the athlete's detrimental behaviour going by undetected. This can occur from a number of reasons: by maintaining a weight within a "normal" range despite employing harmful measures to lose; by affiliating exclusively with other perfectionists in the same sphere so that dysfunctional thinking and/or behaviour actually become the norm among the group; and by the personal biases, attitudes, and level of ignorance from coaches, parents, trainers, and even other athletes on issues of nutrition, obesity and eating disorders (Griffin and Harris, 1996). These are all salient points and will receive their due elaboration in a later section, entitled Practical Guidelines: Detection for Coaches, Trainers, Parents and Other Athletes. Second, if the athlete's destructive behaviour is a covert plea for attention and/or help (for whatever reason), and it does go by unnoticed, she might feel as though her love and acceptance from others are solely dependent on her role as "athlete" and not as a person, in general; in essence, her feelings and her sense of self might be invalidated. Third and finally, by labelling a person with positive or negative descriptors such as, "role model" or "bulimic," there is a risk involved with respect to how the label becomes self-interpreted. This will be touched upon in the following section.

Labelling Theory, Deviance and Perfectionism

individuals who develop anorexia nervosa and bulimia are conformist in their strong commitment to other conventional norms and goals . . . [m]oreover, pre-anorexics and -bulimics display notable conventionality as "model children," the "pride and joy" of their parents, accommodating themselves to the wishes of others. (182, my italics)

Athletes who participate in competitive sport often live their lives according to strict guidelines and working schedules: dietary regimens, training programs, travel itineraries, competition meets, technical and artistic performance requirements, team rosters, codes of behaviour and conduct, etcetera. They conform to so many set standards that it is not difficult to comprehend how their bodies can become yet another arena over which they must control, conquer, and win.

Issues of deviance and labelling are deeply intertwined when discussing aspects of eating disorders. Lemert (1951; 1967) defines primary deviance as, "a transitory period of norm violations which do not affect an individual's self-concept or performance of social roles" (1951:26), so therefore, the initial behaviour of fasting or binging and purging, in any of its forms, delineates the "primary" stage of deviance for those with eating disorders. Secondary deviance is a considerably more threatening condition because it involves the internalization of the deviant behaviour: "secondary deviance is generally prolonged, alters the individual's self-concept, and affects the performance of his/her social roles" (McLorg and Taub, 1987:185). This acceptance of one's aberrant identity may come about from being labelled outright, as deviant. A heightened awareness to an athlete's erratic eating and/or training behaviours may ultimately lead one to label her with an eating disorder. Entitling someone with the "anorexic," "bulimic," "bulimarexic," or "eating disordered" label may have various, conflicting effects. Indeed, it may cause an athlete to take pride in her deviant behaviour, since restrictive diets and regimented exercise represent extended efforts at self-control, self-mastery, strength and willpower. Correspondingly, if she is labelled anorexic, but doesn't see herself as "thin enough" to warrant the label granted to the stereotypical, emaciated figure of an anorexic, she might take further measures to "live up to" that classification. In fact, McLorg and Taub's (1987) study discovered that, when the anorexics in their sample of support-group members were first termed as such by friends, family, or medical personnel, they vigorously denied the label: "[t]hey felt they were not 'anorexic enough,' not skinny enough" (184). On another point along the eating disorder continuum, many labelled bulimics resent their designation and deem the title to be humiliating and offensive because it implies that they lack the willpower to withstand food totally, hence, they consider themselves "failed anorexics" (own term). Even more specifically, the subset of athletes with eating disorders may feel as though they are simply being "ultra healthy" by intensifying their training regimens or restricting their nutritional intake, and may begrudge the label of "anorexic" or "bulimic" altogether.

The Anorectic-Bulimic Conflict and Approach-Avoidance Theory

Other authors have noted that, due to the fear of weight gain, individuals with eating disorders develop an approach-avoidance conflict to food (Vogler, 1993; Harper-Giuffre and MacKenzie, 1992). At any time, one of the two tendencies may win out over the other. When the approach to food is dominant, binge eating occurs. After binge eating, the fear of weight gain strengthens the avoidance response which motivates behaviours like vomiting, laxative abuse, fasting, and excessive exercise. After a period of food restriction, the strength of the food preoccupation increases and drives the individual toward eating and the possibility of losing control and binging. The alternation between approach and avoidance accounts for the behavioural manifestations of eating disorders and for changes in body weight over time. Patients who rapidly alternate between approach (binge eating) and avoidance (purging) are considered to be engaged in bulimic behaviour. Those who immerse themselves in behaviours of avoidance for long periods of time are first diagnosed "preclinical anorexic" (Schlundt and Johnson, 1990: 24) and after sufficient weight loss has occurred, are considered anorexic.

According to Holmgren, patients may be in the anorexic phase, the bulimic phase, or a transitional period at any given time (24). This theory functions well as a labelling tool for eating disordered patients, and athletes in particular, because of their tendency to fluctuate between binging, purging, and restricting at any given time. For the anorexic athlete who has completed her competitive season, she might enter a binging phase because she no longer has to worry about her appearance being judged in competition. For the lightweight rower who wishes to make a specific "weight class" for competition, this event might propel her into a pre-clinical anorexic phase. Holmgren's conceptualization has some advantages over the approach embodied in the DSM-III-R (APA, 1987) in that it avoids making arbitrary distinctions between individuals who differ solely in body weight. Body weight, rather than being a feature that enters into the diagnosis, is merely a complication or consequence of the particular phase of the eating disorder. Holmgren's anorectic-bulimic conflict allows the attending clinician, coach or parent to be prepared realistically, for changes in body weight and lapses between anorexic and bulimic behaviour patterns. The clinician specifically, need not be concerned with changing the diagnosis when these lapses occur; instead, he or she can attend to the underlying problem of weight phobia and the resulting approach-avoidance conflict with its various behavioural manifestations.

Overall, assigning the label of "eating disorder" to an athlete can result in several different scenarios; consequently, recognizing what kind of athlete is at risk, and determining which sports are most susceptible to body image disturbances and weight preoccupation, are imperative.

Athletes and Eating Disorders: Who Is At Risk?

Two such studies, worth mentioning for their unique perspective and notable contribution to the current body of literature, include the Blouin and Goldfield examination of "Body Image and Steroid Use Among Male Bodybuilders" (1995); and the investigation by Sundgot-Borgen on "Risk and trigger factors for the development eating disorders in elite female athletes" (1994). Blouin and Goldfield tested the hypothesis that male bodybuilders may be at risk for the same type of body dissatisfaction that anorexics exhibit, but from the opposite standpoint. The term "reverse anorexia", describes the fear and belief held by many male bodybuilders, that they are too small when in fact, they are actually large and muscular (160). This attitude may account for many "unhealthy or dangerous practices" associated with the sport, such as steroid use and dehydration (Blouin andGoldfield, 1995:160; Anderson et al., 1995:52). The results of this study indicate that there is a subgroup of male bodybuilders who "exhibit a profile of body-related attitudes and psychological characteristics similar to those commonly seen among eating disorder patients and associated with anabolic steroid use" (163). Using standard, clinical inventories like the EDI (Eating Disorder Inventory; Garner, Olmstead, and Polivy, 1983), the Rosenberg Self-Esteem Scale (Rosenberg, 1965) and the BDI (Beck Depression Inventory; Beck, Ward, and Mendelson, 1961), Blouin and Goldfield reveal that male bodybuilders experience greater body dissatisfaction than other athletes (164). Specifically, the bodybuilders report a "drive for bulk" to gain weight and enlarge various body parts (as opposed to the anorexic "relentless pursuit of thinness") in spite of the fact that they are more muscular and heavier than most other athletes in comparison (164). Of striking interest, is the fact that all the bodybuilders in this inquiry share a "demand" for perfection (be it physical, or otherwise), feelings of ineffectiveness, low interoceptive awareness, and low self-esteem (164). The authors cite that the experience of being underweight as a young adolescent male has a significant negative impact on body image, self-esteem, and social adjustment (164). While the bodybuilders in Blouin and Goldfield's investigation were not underweight by any means, their perceived ideal body was exceedingly larger than their current body, which provides surprisingly similar commonalities in the literature on body image distortion between this subgroup and eating disorder patients. This correlation is evidence that more research on body image disturbance needs to be done on a wider scale, among different types of athletes and between sexes as opposed to being relegated only to female athletes.

Sundgot-Borgen's examination of risk and trigger factors that may be responsible for precipitating the onset or exacerbation of eating disorders, also pushes beyond the typical scope of conventional studies. Her large sample size for one (N = 522), provides impressive statistics from which to make more valid generalizations and hypotheses. Not only does her research reinforce what has already been documented in the literature, that "eating problems occur with greatest frequency in sports where athletes are encouraged to be thin for either performance or appearance" (Sundgot-Borgen, 1994:417), but it also raises important issues about the role of the coach. This study identifies several risk factors associated with the development of eating disorders in athletes. Dieting at an early age, as a result of the coach recommending that the athlete lose weight to improve performance, is associated with the general adoption of pathogenic weight control methods. It is revealed that the risk for eating disorders increases if dieting is unsupervised (Sundgot-Borgen, 1994:418); athletes with eating disorders may not seek dietary supervision for fear their disorder will be discovered. In addition, the research uncovers that most athletes have little knowledge about proper weight loss methods and receive their information in haphazard ways (from friends, magazines, etc.). Such diets are unlikely to account for the high energy requirements necessitated by strict training schedules or the fact that maturing females have special nutritional requirements. Sundgot-Borgen's study is especially poignant with respect to this paper, because of the value she places on proper nutrition for the pre-pubescent female athlete, which is the age cohort that comprises the population of the current generation of most aesthetic sports.

The question therefore remains, what can be done to prevent or intervene these problems within the context of competitive sport? The next section will provide practical ideas and possible topics for further discussion in: approaching athletes who exhibit clinical signs and symptoms, acknowledging the issues that surround weight-preoccupation and eating disorders, educating coaches, parents and other athletes, and questioning the current cultural context which allows these problems to flourish.

Practical Guidelines: Detection for Coaches, Trainers, Parents and Other Athletes

The roles of the coach, trainer, parents, and even teammates are extremely important in the early recognition of signs and symptoms of disordered eating and weight preoccupation among athletes. Early detection is essential due to the serious life-threatening risks associated with the combination of intense exercise with anorexia nervosa and/or bulimia. In an attempt to educate coaches on the identification of signs and symptoms, Dr. Pierre Leichner (1986) itemizes a number of important predisposing factors and personality traits which are of particular relevance to athletes. Most of these signs are akin to the typical characteristics of neurotic perfectionism, mentioned earlier: "high self-expectations, a rigid and obsessional approach to reaching goals, difficulties in accepting less than 100 per cent performance, a high emphasis on emotional control, and an underlying sense of poor self-esteem" (66).

In terms of factors which encourage the development of destructive weight-control behaviour, it is imperative to understand how the type of sport played and the level of competition may act as catalysts in encouraging the athlete to feel overwhelming pressure to control her body and/or emotions. Sports which emphasize leanness for optimal performance, and judge athletes on the basis of appearance, are riskier to their participants in terms of fostering weight preoccupation and leading possibly, to eating disorders. Sports played on the varsity, national, international or professional levels demand high calibre athletes who can perform for the media, the crowd, their coach, their school, their country or even their sponsors. Endorsements constitute a large part of what drives many coaches to push their athletes as hard as they do. In order to maintain sponsorship for clubs and secure the coaches' own jobs and reputations, they must ensure the consistent, successful performances of their athletes, which may verily come at the expense of their athletes' physical well-being.

Many of the early signs of eating disorders are not specific and will be found in many athletes and casual exercisers; however, when several of these are observed simultaneously during a prolonged period (several weeks) they should alert the coach or parent to the possibility of a developing eating disorder. These signs may be first witnessed at meal times. They may include an unusual degree of preoccupation with the number of calories being eaten, a gradual restriction of the types of food eaten, an increasing number of excuses for not wanting to eat with others, a change in eating behaviours such as cutting food up in small amounts and chewing it for long periods, or alternatively, gulping down large amounts of food in a short span and disappearing shortly thereafter. During this time the person may also become more withdrawn socially, more irritable and depressed. Athletic performance may become more erratic. Approaching an athlete who is suspected of having an eating disorder requires tact and caution. Leichner (1986) advises an interview approach in a calm and private environment, because athletes are very often ashamed of their symptoms and anxious about the consequences of being "discovered." For them, the fear about weight gain, loss of control of eating, and dissatisfaction with their bodies are very real and should be accepted by the interviewer. But perhaps the most significant point to convey is that anorexia nervosa and bulimia nervosa must be considered serious problems irrespective of whether the sufferer is of "normal" weight or seriously underweight. If the behaviour and sense of self-worth are equally negative and destructive, then it should be reflected in the concern and response initiated.

Conclusion: Where To Go From Here?

Clearly there are a number of sports like gymnastics, figure skating, and dance where success is not only determined by technical ability but by grace and physical appeal, and therefore, an ultra-slender form confers an important performance advantage. But as a consequence, the typical female athlete confronts body image pressures at a number of levels from those performance-related pressures reinforced by coaches and trainers, to those inherent in the judging criteria which give physically attractive athletes "the winning edge". Given previous research on women with eating disorders that focuses on personality characteristics related to perfectionism and high achievement expectations, the question remains, "to what degree are personal and contextual variables involved in eating disorders in high-performance athletes?"

More research is needed to determine how athletes from the technical, power, and other non-traditional sporting realms (in terms of not being traditionally related to the literature on eating disorders) are affected by sociocultural standards of appearance, as compared with their aesthetic and endurance-sport counterparts. There needs to be more education and awareness-raising of coaches, parents and athletes at all levels of competition and recreation alike, to bring this problem to the forefront and effect lasting change. There is also a lack of research on traditionally male-dominated sports and their expectations of appearance or performance as a function of body weight.

All of the issues raised in this paper are pivotal in the realms of sport, psychology, sociology, nutrition, and a number of other related fields; they must be taken seriously. The personal cost to the athlete is high because of the severe and even deadly consequences of eating disorders. Ultimately, the cost to the sports themselves will be exorbitant if participation is considered dangerous by health professionals, physical educators, and parents alike. Research on the development of eating disorders, treatment, awareness, continued education, and prevention must be considered a priority.

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