Performing Well but not Appreciating it – A Trait Feature of Anorexia Nervosa

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In this Papers Podcast, Professor Kerstin von Plessen discusses her co-authored JCPP Advances paper ‘Performing well but not appreciating it – A trait feature of anorexia nervosa’ (

There is an overview of the paper, methodology, key findings, and implications for practice.

Discussion points include:

  • What is currently known about the relationship between perfectionism and anorexia nervosa.
  • Insight into a novel behavioural method for measuring perfectionism and why it is important to look beyond self-evaluation reports.
  • What makes self-evaluation reports limited in comparison to the novel behavioural method.
  • The implications of participants, who have recovered from anorexia nervosa, having evaluated their performances significantly more negatively than their respective controls.
  • Implications of findings from clinicians and child and adolescent mental health (CAMH) professionals.

In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are The Journal of Child Psychology and Psychiatry (JCPP)The Child and Adolescent Mental Health (CAMH) journal; and JCPP Advances.

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Kerstin von Plessen
Professor Kerstin von Plessen

Kerstin Jessica von Plessen is Professor of Child and Adolescent Psychiatry at the University of Lausanne and head of division of Child and Adolescent Psychiatry at the University Hospital of Lausanne, the CHUV. Her research covers the range of psychopathology and that relate to the development of mental health of children and young people with a strong interest for public health questions. During her career she has always had a clinical focus on young people with eating disorders.

Plessen completed her postgraduate training in child and adolescent psychiatry and psychotherapy at the University of Bergen, in Norway, where she also completed a PhD on the brain development of children with Tourette syndrome, in close collaboration with Columbia University in New York. She was Professor in Child and Adolescent Psychiatry at the University of Copenhagen from 2011 to 2017 where she established a group of researchers whose work focused on developmental pathways in children and adolescent with neuropsychiatric disorders and those at risk for mental health problems. In December 2017 she moved to the University of Lausanne to take on the clinical and research lead of the division and to reorganize the services to achieve a coverage of the public health sector for the young people of the region.


[00:00:01.400] Jo Carlowe: Hello, welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a Freelance Journalist with a specialism in psychology. In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are the Journal of Child Psychology and Psychiatry, commonly known as JCPP, the Child and Adolescent Mental Health, known as CAMH, and JCPP Advances.

Today, I’m interviewing Professor Kerstin von Plessen, of the Department of Psychiatry at University Hospital, Lausanne, Switzerland. Kerstin in a joint author of the paper, “Performing Well But Not Appreciating It – A Trait Feature of Anorexia Nervosa,” recently published in JCPP Advances. This paper will be the focus of today’s podcast.

If you’re a fan of our Papers Podcast series, please subscribe on your preferred streaming platform, let us know how we did, with a rating or review, and do share with friends and colleagues.

Kerstin, thank you for joining me, welcome. Can you start with an introduction about who you are and what you do?

[00:01:10.630] Professor Kerstin von Plessen: Hello, and thank you for having me. As you said, I’m a Professor of Child and Adolescent Psychiatry at the University Hospital of Lausanne, and I’m also heading the Division of Child and Adolescent Psychiatry here in Lausanne. And before that, I was a Professor in Copenhagen, and that’s also where we performed the study, together with Tine Schuppli Hjerresen and all other colleagues from Copenhagen University.

[00:01:35.240] Jo Carlowe: Thank you very much. So, we’re going to look at your paper today. This is, “Performing Well But Not Appreciating It – A Trait Feature of Anorexia Nervosa,” recently published in JCPP Advances. Can you give us an overview of the paper to set the scene?

[00:01:50.170] Professor Kerstin von Plessen: So, we compared a group of 33 adolescent girls during their first episode of anorexia nervosa, and we had 29 female controls of the same age, so they were all 16 years. And then, we were able to recruit 23 adolescent girls who had recovered from anorexia nervosa, and they had the age of 18 years, and we had 23 female controls, that were obviously also at the age of 18. And we didn’t exclude comorbidities in the group of children, or of young girls with anorexia nervosa, because we said, “Well, it’s important, also, to keep the comorbidities, because they are often really present in our clinic.” The only thing we did was to exclude those who had an autism spectrum disorder, because that would really also change the appreciation of your performance if you have an autism spectrum disorder.

And then, we asked them to perform this Go/NoGo task, quite a simple performance task, where we also put in a difficulty. So, we had a rule shifting paradigm, that means that we showed them three stimuli, but the significance of the stimuli, of two of the three stimuli, changed during the blocks that we had. So, we had 28 blocks in total, so we had two sessions, and each session consisted of 14 blocks, and then, we also interfered one on the other with rule shifting in between, to make it a bit – little bit more difficult for them. And we also had blocks where the stimuli were not as easy to read as in other blocks. So, we really had some features that made this task a little bit difficult.

And that could also have contributed to the evaluation. So, after each block, they had this evaluation, a self-evaluation, on a continuous scale from “poor” to “perfect.” So, it was really a visual, analogue scale, and they could position themselves on this scale, and they had to do it after each block. And then, afterwards, we had a composite score of the performance, including the reaction time, and also, the error rate, and on the other hand, we could put that in relationship to their evaluation.

At first, we had been thinking about recruiting young girls before the onset of anorexia nervosa, but we figured out that this would be a very difficult study to perform, and that’s why we said, “Well, if we could have a recovered group, you would have this trait also examined.” So, that was the outset for this study, and in this study, we could show in a behavioural paradigm, and I think that’s the most novel feature of this paper, and of this study, we could really show that, yes, in a behavioural paradigm, those girls in both groups, those who had an anorexia ongoing, and those who had recovered from it, they were more critical towards their performance than the control groups.

[00:04:59.560] Jo Carlowe: Thank you. Just taking a step back, what is currently known about the relationship between perfectionism and anorexia nervosa?

[00:05:08.830] Professor Kerstin von Plessen: I mean, perfectionism is really very much associated, also, to low self-esteem, to negative self-concept, and to, also, something you would call for “clinical perfectionism.” So, that meaning that, in anorexia nervosa, you have often this characteristic that you strive for weight loss, you strive for an appearance, which is a form of a clinical perfectionism, and that has been identified quite clearly in terms of risk factor for onset, but also, a factor for, also, relapse in anorexia nervosa. Because we know that it’s a risk factor for all kinds of anorexia nervosa, or states of anorexia nervosa, it’s clear that it would be a very interesting factor, also, to include it in an individualised treatment.

So far, in the child and adolescents literature, there are few studies who have included it and have targeted it, but there’s one study I just wanted to highlight from Australia, who actually included a CBT module, or perfectionism, in an FBT approach, so Family-Based Treatment approach. That is the most known, the most evidence-based, approach for young people with anorexia nervosa, and actually, they showed good results in their study. It was quite a small study, but it seems that there’s really an interest to pursue for anorexia nervosa and perfectionism, also, in terms of treatment approaches.

[00:06:45.120] Jo Carlowe: Hmmm, that’s really interesting, and returning to your study. So, perfectionism has been studied predominantly by the use of self-report questionnaires. Your study offers a novel behavioural method for measuring perfectionism. Kerstin, can you describe the method and explain why it was important to look beyond just self-evaluation reports?

[00:07:07.220] Professor Kerstin von Plessen: What is im – what was important for us is, also, that we wanted to use neutral stimuli. So, we didn’t want to use stimuli that were associated to eating or emotions. So, we really tried to find a cognitive paradigm, and that was a simple Go/NoGo task. I think most people know these tasks. You get to see a stimuli and then either you have to press the “Go” button or the “NoGo” button, and then you would measure reaction time. And you would also measure error, so commission errors, where you would press when you’re supposed not to press, and with that paradigm, we had quite a basic measure of a performance task.

And then, we ask the young girls, or the not so young girls, because in the recovered group they were 18-years-old, and in the onset group they were 16-years-old, in mean age, and we asked them to evaluate how they did in this task. And we did this 28 times per person, because we had 14 blocks twice. And so, really after each block they were supposed, on a scale, to indicate how they were doing, and based on these measures, we could have a composite of the performance score, and also, of the evaluation that they had.

If you go back to perfectionism, I would say it’s really a measure of perfectionism which is very self-oriented. As you will probably know, there has been a lot of discussion in the last years about perfectionism, and you should also try to distinguish self-oriented perfectionism and socially prescribed perfectionism, and here we really put forward self-oriented perfectionism. I think that’s important to stress, also, for this study.

[00:09:04.170] Jo Carlowe: And can you say anything more about why it was so important to look beyond just self-evaluation reports, or what makes self-evaluation reports more limited, or so limited?

[00:09:16.390] Professor Kerstin von Plessen: Well, I think it’s really – it’s a more objective measure, and it’s also something you could think of introducing into the clinics, because this is really quite convincing. If I had done my test myself, and then afterwards, I see, well, I – actually, I evaluated myself much worse than other people who did the same test, that’s something to share, and that’s really something to – also, to have some learn experience for the people.

Whereas, really, if you have a self-report on perfectionism, it’s difficult to say, “Well, probably you’re more negative than other people. Have you thought about this?” And then you would say, “Well, actually, I’m not better than other people,” or, “I’m worse than other people.” It’s more difficult to discuss this than to really have an objective measure. And, also, it was important for us to be able to show that this is a group which actually, objectively, has a lower self-evaluation than their peers.

[00:10:21.730] Jo Carlowe: Thank you. Is there anything more you want to say about the methodology?

[00:10:25.820] Professor Kerstin von Plessen: Just, also, concerning the results, to stress that the younger group, so the group with the ongoing anorexia nervosa, did as well as did the control group, and the recovered group, they did better than the control group. And that was somehow a bit astonishing to us, because somehow, the adult literature often showed that there was rather a slower reaction time in the anorexia group, and so, we can state that that was not the case. So, it’s interesting, that means that trying to distinguish really chronic effects more from pathological effects, so, trying to say, “Well, the anorexia itself does not make that you’re not performing as well.”

Then in a second step – that’s also one of the limitations, of course, when we had the recovered group, those were girls who had rather early onset of the anorexia nervosa, and we could also see in the recovered group, compared to the now onset group, they had had earlier onset. And they had been recovered until the age of 18, when we saw them in our study. So, probably it was somehow a selected group that did better and who had a good recovery. So, that’s one of the limitations, but still, it’s interesting to see that actually their performance was as good or superior to the control group.

[00:11:59.540] Jo Carlowe: Can we focus on something you mentioned earlier…

[00:12:02.410] Professor Kerstin von Plessen: Hmmm hmm.

[00:12:03.410] Jo Carlowe: …in the findings? So, this was the fact that you’ve just mentioned that despite being recovered from anorexia nervosa, recovered participants in your study evaluated their performance significantly more negatively than their respective controls, talking about the recovered group here. I’m wondering what the implications are of that finding.

[00:12:22.940] Professor Kerstin von Plessen: One of the implications, clearly, is that perfectionism is not only associated to illness. So, it does not mean that it only concerns everything that is around eating, about appearance, but that’s something that seems to be somehow trans-life for those young girls, that means that they are really evaluating whatever they do in a way that is more negative than their peers. And I think that’s quite an important point to put forward for also the approach to eating disorder.

[00:12:56.870] Jo Carlowe: Does it imply that on some level they have not fully recovered?

[00:13:00.440] Professor Kerstin von Plessen: Exactly. So, it may imply that they have not really recovered totally from an illness, but the question is, can you recover in your life from something like an eating disorder? Because if you think that maybe this perfectionism as a trait, a feature that has also been there already before the onset of the anorexia nervosa, then, in this case, probably you will always somehow stay with it. But it’s clear that in order to be also protected for relapse in the future, it might be very important to address this feature, and to say, “Well, what can we do in order to help you get resilient for just this risk that we can see here?”

[00:13:43.890] Jo Carlowe: Right. That brings me onto my next question, which is, what are the implications of your findings, overall, for Clinicians and CAMH professionals?

[00:13:52.340] Professor Kerstin von Plessen: I think one of the implications may be to think more specifically about how can we target, how can we add a module, in order to address this trait feature in young girls, but probably also in young boys with anorexia nervosa? And to follow-up studies, also, where we use the usual approach, as, for example, the FBT, and then, also, add modules that address specifically the perfectionism. I would also be very interested in the socially prescribed perfectionism, especially in terms of onset of the disorder, because probably that plays an important role. That’s something that we haven’t been able to look at in this study.

[00:14:40.579] Jo Carlowe: So, are you thinking about things like school-based interventions for that?

[00:14:44.680] Professor Kerstin von Plessen: Maybe to start with, to define its role, because what we see in the clinic is that socially prescribed perfectionisms plays a big role for everything that is in – linked to social media and social networks. We hear people expressing, also, this way into the disorder, that quite has changed in the last years, where more and more it is put forward, also, the exposure to social media. And I think that is really a very good example of a socially prescribed perfectionism.

[00:15:23.149] Jo Carlowe: And do you think Clinicians and CAMH professionals take in that factor about perfectionism in their current interventions?

[00:15:31.910] Professor Kerstin von Plessen: Until now, it’s – it is a little systematised. I mean, there are, as I mentioned, also, some small studies doing it, but the usual approaches do it less so. There is EDI, so the most used inventory for eating disorder, there is already a scale looking in those two types of perfectionism, so that’s important. So, the information is there, but it’s not so easy to address this, to target this, in your interventions. I mean, speaking of this, I think there would probably be a need, also more broad than only in eating disorders, to address the socially prescribed perfectionism in girls. Because we see a drop in self-esteem in girls entering puberty, and we see, also, these rising rates of crisis in young girls, so I think there is something to look at.

[00:16:30.329] Jo Carlowe: Absolutely, thank you. Just returning to the paper, Kerstin, is there anything else that you would like to highlight in the paper itself?

[00:16:37.040] Professor Kerstin von Plessen: The fact that when we use this EDI scale, because we also used it in our study, actually there was not a difference between the different groups that we have examined, which poses some questions for us, so we couldn’t really explain that very well. Probably there is also a difference in age, maybe. That’s an open question.

[00:17:03.030] Jo Carlowe: Hmmm, so a lot more to research.

[00:17:05.760] Professor Kerstin von Plessen: Yeah.

[00:17:06.949] Jo Carlowe: So, are you planning any follow-up research, or is there anything else in the pipeline that you would like to…?

[00:17:12.380] Professor Kerstin von Plessen: Well, actually, what I just mentioned, the socially prescribed perfectionism and the onset of eating disorder, that’s really a topic that is very important and that we will try to address in the future.

[00:17:30.220] Jo Carlowe: Hmmm, I look forward to hearing about that. Finally, Kerstin, what is your take home message for our listeners?

[00:17:32.330] Professor Kerstin von Plessen: Well, I think the take home message is really that perfectionism seems to be a trait feature, at least in young females suffering from anorexia nervosa, and, also, for those who have recovered for it. And with this study we cannot really determine whether it has an influence on the onset of the disorder, but it seems that exposure to perfect images of the other may also provoke an onset of the disorder, and that’s something to follow-up in the future.

[00:18:06.370] Jo Carlowe: Kerstin, thank you ever so much. For more details on Professor Kerstin von Plessen, please visit the ACAMH website,, and Twitter @ACAMH. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoyed the podcast, with a rating or review, and do share with friends and colleagues.

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