Received: 21 October 2020 Revised: 21 January 2021 Accepted: 28 January 2021

DOI: 10.1002/eat.23483

REVIEW

Perfectionism interventions targeting disordered eating:

A systematic review and meta-analysis

Katherine Robinson BSc (Hons)1 | Tracey D. Wade PhD1,2

1
Flinders University, Bedford Park, South Australia, Australia
2
Blackbird Initiative, Órama Research Institute, Bedford Park, South Australia, Australia

Correspondence
Katherine Robinson, Discipline of Psychology, Abstract
Flinders University, GPO Box 2100, Adelaide, Objective: Perfectionism is a risk factor for depression, anxiety, and eating disorders,
5001 SA, Australia.
Email: [Link]@[Link] and perfectionism interventions show evidence of the impact on the development
and maintenance of these disorders. A systematic review and meta-analysis were
Funding information
Lauren Corena Scholarship Breakthrough conducted of studies using perfectionism interventions that included measures of dis-
Mental Health Foundation ordered eating/body image concerns. The primary aim was to investigate the impact
Action Editor: Kelly Klump on perfectionism and disordered eating/body image concerns, with a secondary aim
of examining the impact on depression and anxiety.
Method: The systematic review was conducted using Medline, PsycINFO, and
Scopus. Grey literature was sought via ProQuest Dissertations and Theses Global.
Effect size estimates for the meta-analysis were calculated using between- and
within-group comparisons.
Results: Eight studies were included in the between-group analysis and nine studies
for the within-group analysis. Perfectionism interventions were effective in reducing
perfectionism and disordered eating with large effect sizes, and in reducing depres-
sion and anxiety with moderate effect sizes. Studies included both clinical and non-
clinical populations. Substantial heterogeneity was present across most analyses.
Discussion: Eating disorder treatments may benefit more from the inclusion of per-
fectionism interventions than depression and anxiety treatments. Possible reasoning
for these variations between symptom reduction is discussed. This report provides
important early evidence for the efficacy of perfectionism interventions, however,
the limited number of publications in this area, the presence of heterogeneity, and
lack of diversity in participant populations limits the generalizability of these findings.
Future research is needed to determine whether eating disorder treatments may ben-
efit from the routine inclusion of a perfectionism component.

Resumen
Objetivo: El perfeccionismo es un factor de riesgo para la depresión, la ansiedad y los
trastornos de la conducta alimentaria, y las intervenciones sobre el perfeccionismo
muestran evidencia del impacto en el desarrollo y mantenimiento de estos trastornos.
Se llevó a cabo una revisión sistemática y metanálisis de los estudios que utilizan
intervenciones sobre el perfeccionismo que incluían medidas de preocupaciones de
alimentación alterada/imagen corporal. El objetivo principal era investigar el impacto

Int J Eat Disord. 2021;54:473–487. [Link]/journal/eat © 2021 Wiley Periodicals LLC 473
474 ROBINSON AND WADE

en el perfeccionismo y las preocupaciones con la imagen corporal/alimentación

alterada, con un objetivo secundario de examinar el impacto de este en la depresión y
la ansiedad.
Métodos: La revisión sistemática se llevó a cabo utilizando Medline, PsycINFO y
Scopus. La literatura gris fue buscada a través de ProQuest Dissertations y Theses
Global. Las estimaciones del tamaño del efecto para el metaanálisis se calcularon
utilizando comparaciones entre y dentro del grupo.
Resultados: Se incluyeron ocho estudios en el análisis entre grupos y nueve estudios
para el análisis dentro del grupo. Las intervenciones de perfeccionismo fueron
eficaces para reducir el perfeccionismo y la alimentación anormal con grandes tam-
años de efecto, y en la reducción de la depresión y la ansiedad con tamaños de efecto
moderados. Los estudios incluyeron poblaciones clínicas y no clínicas. La hetero-
geneidad sustancial estuvo presente en la mayoría de los análisis.
Discusión: Los tratamientos para los trastornos de la conducta alimentaria pueden
beneficiarse más de la inclusión de intervenciones de perfeccionismo que los
tratamientos de depresión y ansiedad. Se discute el posible razonamiento para estas
variaciones entre la reducción de los síntomas. Este informe proporciona importante
evidencia temprana de la eficacia de las intervenciones de perfeccionismo, sin
embargo, el número limitado de publicaciones en esta área, la presencia de hetero-
geneidad y la falta de diversidad en las poblaciones participantes limitan la general-
ización de estos hallazgos. Se necesitan investigaciones futuras para determinar si los
tratamientos para trastornos de la conducta alimentaria pueden beneficiarse de la
inclusión rutinaria del componente de perfeccionismo.

KEYWORDS
anxiety, depression, disorder, eating, efficacy, intervention, perfectionism, prevention

1 | I N T RO DU CT I O N Perfectionism is considered a transdiagnostic risk factor for multi-

ple psychopathologies, including obsessive compulsive disorder
Perfectionism is a multi-faceted construct with key components includ- (OCD), depression, anxiety, and eating disorders (EDs) (Bardone-Cone
ing high personal standards, excessive concern over mistakes, fear of et al., 2007; Egan, Wade, & Shafran, 2011; Sassaroli, Gallucci, &
negative evaluation, and self-criticism (Frost, Marten, Lahart, & Ruggiero, 2008; Shafran, Cooper, & Fairburn, 2002). Perfectionism is
Rosenblate, 1990). The terms perfectionistic standards (PS) and perfec- a proposed risk factor both in the development and maintenance of
tionistic concerns (PC) have been suggested to conceptualize the two eating disorders as it precedes disorder onset and is present through-
dimensions of perfectionism identified in factor analyses (Smith & out the disorder and early stages of recovery (Bardone-Cone, Sturm,
Saklofske, 2017). PS encompasses high personal standards and self- Lawson, Robinson, & Smith, 2010). Perfectionism has a marked impact
oriented forms of perfectionism, whereas PC is associated with concerns on ED maintenance through its association with overvaluation of
over mistakes, doubts about actions, and socially prescribed perfection- shape and weight (Smith, Simmons, Flory, Annus, & Hill, 2007). Shape
ism (Stoeber & Otto, 2006). Perfectionism has been described as both an and weight overvaluation formulate the belief that accomplishing a
adaptive and maladaptive trait (Bieling, Israeli, & Antony, 2004; Trum- lower order and tangible goal (e.g., eating less than 1,000 cal a day) is
peter, Watson, & O'Leary, 2006) but evidence suggests that both PC and imperative to accomplishing a higher order and more abstract goal
PS are associated with negative impacts on mental health, higher levels (e.g., the feeling of being in control). As such, when lower order goals
of neuroticism, and greater perceptions of stress (Enns, Cox, Sareen, & are not achieved, higher order goals are also viewed as unattainable,
Freeman, 2001; Limburg, Watson, Hagger, & Egan, 2017). Emerging evi- leading to greater psychological distress (Watson, Raykos, Street,
dence suggests that working to achieve high (as opposed to perfectionis- Fursland, & Nathan, 2011). Targeting perfectionism is hypothesized to
tic) standards exists separately from perfectionism and is not considered reduce disordered eating in both at-risk populations who experience
harmful (Blasberg, Hewitt, Flett, Sherry, & Chen, 2016; Flett & disordered eating without meeting the criteria for a clinical diagnosis,
Hewitt, 2006; Gaudreau, 2019; Osenk, Williamson, & Wade, 2020). and in those who have a diagnosis of an ED.
ROBINSON AND WADE 475

Two meta-analyses have so far investigated the impact of perfection- body) ADJUNCT TO (image OR concern OR dissatisfy*) OR
ism interventions on various psychopathologies. A 2019 review by Suh, dysmorph*). A grey literature search was conducted using the same
Sohn, Kim, and Lee examined depression and anxiety symptoms, incorpo- search terms through the database ProQuest Dissertations and The-
rating 10 studies which utilized face-to-face and online interventions to ses Global. Additionally, attempts were made to contact the authors
target perfectionism. Eight of the studies targeted a population with ele- of the papers included in the meta-analysis to enquire about relevant
vated perfectionism, one study targeted individuals with an eating disor- unpublished or ongoing research.
der diagnosis, and one targeted elevated perfectionism and a diagnosis of
OCD. Their analysis focused solely on the comparison of intervention
groups to control groups (between-group analysis) to provide estimates of 2.2 | Eligibility criteria
the efficacy of perfectionism interventions in reducing symptoms of per-
fectionism, depression, and anxiety. Effect size estimates indicate both Studies were considered eligible for systematic review if they evaluated a
perfectionistic strivings (g = −0.48, 95% CI: −0.71, −0.25) and perfection- perfectionism intervention that included disordered eating or body image
istic concerns (g = −0.55, 95% CI: −0.83, −0.26) are responsive to inter- as an outcome measure, regardless of whether the format was a case
ventions as are symptoms of depression (g = −0.62, 95% CI: −1.04, −0.20) series, randomized control trial, qualitative assessment, or other. The stud-
and anxiety (g = −0.49, 95% CI: −0.74, −0.24). These findings are congru- ies needed to be written in English and published in peer review journals,
ent with an earlier meta-analysis performed by Lloyd, Fleming, Schmidt, irrespective of whether the results published were qualitative or quantita-
and Tchanturia (2015) which was conducted using pre-post trial results tive. Subsequent inclusion in the meta-analysis required only the studies
(within-group analysis) only. They noted a moderate reduction in anxiety which produced quantitative data for use in calculation of an intervention
(g = 0.52, 95% CI: 0.23, 0.81) and depression (g = 0.64, 95% CI: 0.35, 0.92), effect size, and which offered perfectionism treatment as a standalone
and a large reduction in perfectionism (concern over mistakes g = 1.32, rather than augmented treatment. All papers which did not include mea-
95% CI: 1.02, 1.64, personal standards g = 0.79, 95% CI: 0.44, 1.12, self- sures of symptom severity for both disordered eating/body image and
oriented perfectionism g = 0.81, 95% CI: 0.41, 1.20). Eating disorder symp- perfectionism were excluded at the final phase of screening for the meta-
toms were also partly investigated; only one study was included that analysis. Studies were excluded if they were based on a pediatric (pre-ado-
addressed the use of perfectionism interventions to reduce disordered lescent) population, did not provide multiple sessions of perfectionism
eating (Wilksch, Durbridge, & Wade, 2008), in individuals with a diagnosis treatment, or addressed perfectionism as a sub-component of a larger
of Bulimia Nervosa. Reductions in objective binge episodes (g = 0.32), intervention with a multifaceted approach. Pediatric populations were
purging (g = 0.50), and shape and weight concerns (g = 3.96) were excluded from this meta-analysis due to a lack of evidence supporting the
observed post-intervention. reliability and validity of using perfectionism measures in this age group
Since the publication of Lloyd et al.'s, 2015 review, an increased (Leone & Wade, 2018). Child-specific measures of perfectionism remain
number of studies have examined the impact of a perfectionism inter- largely untested for construct validity and the appropriateness of using an
vention on disordered eating and/or body image. Hence the first aim adult conceptualization of perfectionism in children is unknown. Further
of this research is to conduct a systematic review and meta-analysis clarification is needed as to how perfectionism should be measured in chil-
of these studies (which are a subset of all studies examining the dren before including this population in a systematic review.
impact of perfectionism interventions) in order to ascertain effects
sizes for both perfectionism and disordered eating/body image. A sec-
ondary aim was to investigate the impact of perfectionism interven- 2.3 | Meta-analyses
tions on depression and anxiety in order to compare the differential
impact treating perfectionism has on disordered eating. We provide Two meta-analyses were conducted using a random effects model for
both between- and within-group effect sizes to offer comparisons to the constructs of perfectionism, eating disorder behaviors, depression,
the two previous meta-analyses. In addressing these aims, this study and anxiety. Effect size (ES) estimates were calculated for both
intends to provide direction for future research in this area. within-group and between-group data. Within-group estimates com-
pared pre- and post-trial scores in the intervention group, as reported
in the previous meta-analysis of perfectionism interventions (Lloyd
2 | METHOD et al., 2015) to permit comparability to these results. The between-
group estimates compared post-trial scores of the intervention group
2.1 | Search strategy against the control group. Where values were not available or could
not be calculated from the published data, the paper's authors were
A manual literature search was conducted in August 2020 by the first contacted to request the missing information. All requests were com-
author using Scopus, Medline (Ovid), and PsycINFO. The search terms plied with, allowing for all studies to be included in the meta-analysis.
(appearing in either title, abstract, subject heading or keyword) One study (Johnson et al., 2019) did not use a control group and was
included (perfect*) AND (treatment OR therap* OR intervention* OR excluded from the between-groups analysis.
prevention* OR trial* OR analysis or evaluat*) AND (anorexi* OR The Comprehensive Meta-Analysis Program Version 3 (Borenstein,
bulimi* OR “eating disorder*” OR “disordered eating” OR ((weight OR Hedges, Higgins, & Rothstein, 2013) was used to calculate all statistics
476 ROBINSON AND WADE

relating to the meta-analysis (forest plots, heterogeneity, publication concerns, preference was given to EDE-Q as the most commonly
biases) excluding the correlation coefficients. Due to the small number of reported measure, allowing for reliable cross-study comparison.
studies included in this analysis (n < 10), Hedge's g was chosen over
Cohen's d as the estimate for ES. The calculation for Hedge's g applies a
correction factor (J), which is not found in the formula for Cohen's d, 2.4 | Correlation calculations for within group
which allows for a less biased estimate of ES in small samples effect sizes
(Borenstein et al., 2013). ESs were computed using group means (M1 and
M2), group standard deviations (SD1 and SD2), sample size (n1 and n2), Within-group effect sizes were not reported for seven of the nine
and a correction for the correlation between pre- and post-measures (r). papers. In order to conduct a meta-analysis of the pre-post intervention
Where studies included more than one measure of perfectionism, effects, a correlation coefficient was calculated for each construct and
preference was given first to the Frost Multidimensional Perfection- applied across all nine studies. In doing so, the within-group effect sizes
ism Scale-Concern over Mistakes subscale (FMPS-CM) as this mea- were calculated adjusting for the intra-individual/repeated measures
sure was expected to give the most reliable representation of effect. In order to estimate the correlations between measures, the pre-
perfectionistic concerns and is a commonly reported measure, all- treatment and post-treatment (12-week follow-up) data from Shafran
owing for more reliable and accurate cross-study comparison (Bulik et al. (2017) was used as the basis for this analysis. Analyses were con-
et al., 2005). Measures designed to assess eating disorder behaviors ducted using the IBM statistics software SPSS (Version 25). Estimates
or body image concerns were included for the purpose of analysis as were obtained using linear mixed-effect models (LMM) which required
they both relate to the generalizable construct of disordered eating fewer assumptions than repeated-measures ANOVA and accommodated
(or shape and weight concern). Body image measures were reported for missing data using a maximization likelihood. Correlates were esti-
in three studies and the global Eating Disorder Examination Question- mated using an intent-to-treat analysis and included all cases where data
naire (EDE-Q; Fairburn & Beglin, 2008) was used in the remaining six was missing from one or more timepoints. Of the 62 participants who
studies which assessed eating disorder behaviors. In studies using were randomized to treatment in Shafran et al.'s (2017) study, 31 (50%)
multiple measures of eating disorder behaviors or body image did not complete the post-treatment measures.

Records identified through Scopus,

Medline, and PsycINFO Additional records identified
(n = 1124) Records identified through contacted authors (n = 1)
through ProQuest (n = 246)

Number of duplicates removed

(n = 243)

Records screened Records excluded

(n = 1128) (n = 1099)

Full-text articles excluded, with

Full-text articles assessed reasons (n =14)
for eligibility • 10 excluded for not
(n = 29) addressing perfectionism as
primary target
• 2 excluded for not addressing
an at risk/disordered eating
population
Studies included in • 2 excluded for wrong patient
qualitative synthesis population
(n = 15)

Studies included in
quantitative synthesis
(meta-analysis)
(n = 9)
FIGURE 1 PRISMA flow diagram
TABLE 1 Study characteristics for all studies identified which contain perfectionism interventions targeting body image concerns and disordered eating
Target Disordered
Treatment demographic Treatment Perfectionism eating Body image Depression Primary
Study Design Treatment modality primary diagnosis group N Control N N sessions measures measures measures measures Anxiety measures outcome

Grieve et al., 2020M RCT CBT Online self- Self-identified 41 48 8 FMPS, Almost N/A Body Image DASS-21 DASS-21 (anxiety Perfectionism
guided perfectionism Perfect Scale Acceptance and (depression subscale) symptom
ROBINSON AND WADE

(Revised) Action subscale) reduction

Questionnaire

Goldstein, RCT CBT Face to face ED (ED service 28 29 7 FMPS, MPS-H EDE-Q N/A N/A N/A ED symptom
Peters, group outpatients) reduction
Thornton, therapy
& Touyz, 2014 A

Handley, Egan, RCT CBT Face to face Elevated 21 21 8 FMPS, CPQ, DAS EDE-Q N/A BDI-II DASS-21 (anxiety Perfectionism
Kane, & group perfectionism (self-criticism subscale) symptom
Rees, 2015M therapy subscale) reduction

Hurst & Zimmer- Case series FBT + CBT Face to face Anorexia nervosa 3 N/A 9 Child & Adolescent EDE N/A N/A N/A ED symptom
Gembeck, 2019A single cohort Perfectionism reduction
Scale

Johnson Case series CBT Online self- Dysmorphic 31 N/A 8 FMPS N/A Dysmorphic DASS-21 DASS-21 (anxiety Perfectionism
et al., 2019M guided concern Concern (depression subscale) symptom
Questionnaire, subscale) reduction
Multidimensional
Body-Self
Relations
Questionnaire

Kothari et al., 2019M RCT CBT Online guided Elevated 62 58 8 FMPS, CPQ EDE-Q N/A DASS-21 DASS-21 (anxiety Perfectionism
perfectionism (depression subscale) symptom
subscale) reduction

Larsson, Lloyd, Qualitative U Face to face Anorexia nervosa 14 N/A 6 N/A N/A N/A N/A N/A Thematic
Westwood, & assessment group (ED service analysis
Tchanturia, 2018Q therapy inpatients)

Levinson Case series CBT Face to face ED (unspecified; 28 N/A 7 FMPS EDI-II (drive for EDI-II (body N/A The social Intervention
et al., 2017A group inpatients and thinness and dissatisfaction appearance feasibility
therapy outpatients) bulimia subscale) anxiety scale
symptoms
subscale)

Lloyd Case series CBT Face to face Anorexia nervosa 42 N/A 6 FMPS EDE-Q N/A N/A N/A Intervention
et al., 2015A group (ED service feasibility
therapy inpatients)

Shu et al., 2019M RCT CBT Online self- Self-identified 36 24 8 CPQ EDE-Q N/A Revised child Revised child Perfectionism
guided perfectionism anxiety and anxiety and and ED
depression depression symptom
scales scales reduction

Steele & RCT CBT Face to face Disordered eating 15 N/A 8 FMPS EDE-I and EDE- N/A DASS DASS (anxiety ED symptom
Wade, 2008M guided self- (modified Q (depression subscale) reduction
help DSM-5 criteria subscale)
for BN)

Tchanturia, Case series U Face to face Anorexia nervosa 47 N/A 6 FMPS, CPQ N/A N/A N/A N/A Intervention
Larsson, & group (ED service evaluation
Adamson, therapy inpatients)
477

2016A

(Continues)
 478 ROBINSON AND WADE

2.5 | Heterogeneity

Abbreviations: A, augmented or concurrent treatment; BDI, Beck Depression Inventory; DASS-21, Depression Anxiety Stress Scale; EDE-I, Eating Disorder Examination-Interview; EDE-Q, Eating Disorder Examination-Questionnaire; M, eligible for meta-analysis; N
Perfectionism

Perfectionism

ED symptom
reduction

reduction

reduction
symptom

symptom
Anxiety measures outcome Q and I2 were calculated to determine heterogeneity; I2 expresses the
Primary

percentage of variability attributable to heterogeneity rather than sam-

pling error. Possible values range from 0–100% with higher values rep-
resenting greater heterogeneity. Measures of heterogeneity are
DASS-21
susceptible to substantial bias when few studies are included. Hence, I2
N/A

N/A
should be interpreted cautiously and within the context of the meta-
analysis, addressing for potential reasons for heterogeneity (von
Depression

Hippel, 2015).
measures

DASS-21
N/A

N/A

2.6 | Publication bias

Acceptance and

Questionnaire
Body image

Body Image
measures

Action

Publication bias was assessed using Egger's test (Egger, Smith,

N/A

N/A

Schneider, & Minder, 1997). Egger's test provides a Y intercept (from

linear regression) which, if significantly different from zero, indicates
Questionnaire
EDE-Q, Dutch

publication bias is likely present.

Behavior
Disordered

measures

Eating
EDE-Q
eating

N/A

2.7 | Quality assessment

Perfectionism

FMPS, CPQ

All studies included in the final meta-analysis were assessed for

measures

quality using the Consort 2010 checklist for reporting a pilot or fea-
FMPS

FMPS

sibility trial (Eldridge et al., 2016). As the meta-analyses comprised

of case series and randomized control trials (RCTs), a subset of nine
N sessions

items were selected, from the original 40, which were applicable to
all study types. The selected items were: (Item 4a) Eligibility criteria
8

for participants; (Item 5) The interventions for each group with suf-
Control N

ficient details to allow replication, including how and when they

sessions, number of sessions; Q, qualitative data only; RCT, randomized control trial; U, unspecified treatment type.
29

23

44

were actually administered; (Item 7a) Rationale for numbers in the

Treatment

pilot trial; (Item 13a) For each group, the numbers of participants
group N

who were approached and/or assessed for eligibility, randomly

38

28

51

assigned, received intended treatment, and were assessed for each

primary diagnosis

concerns (non-

objective; (Item 13b) For each group, losses and exclusions after
perfectionism

Perfectionistic
demographic

randomization, together with reasons; (Item 15) A table showing

clinical)
Elevated

baseline demographic and clinical characteristics for each group;

Target

N/A

(Item 16) For each objective, number of participants (denominator)

included in each analysis. If relevant, these numbers should be by
classroom
Face to face
Online self-

Online self-
Treatment

randomized group; (Item 17) For each objective, results including

guided

guided
modality

based

expressions of uncertainty (such as 95% confidence interval) for

any estimates. If relevant, these results should be by randomized
Treatment

group; (Item 26) Ethical approval or approval by research review

CBT

CBT

committee, confirmed with reference number. The checklist was

U

applied using a coded response with items given a “Y” if criteria

comparison
Randomized

was met, an “N” if criteria was not met, and a “P” if criteria was
Controlled
Design
(Continued)

trial

partially fulfilled.
RCT

Additionally, a second quality assessment tool was used to specif-

Wilksch et al., 2008M

ically assess the quality of RCTs included in the meta-analysis. The

Wade et al., 2019M
et al., 2018M

Cochrane Risk of Bias (II) tool assesses individually randomized, paral-

TABLE 1

lel group trials, and provides a rating to differentiate those of “Low”

Valentine
Study

versus “High” or “Some” concern for risk of bias (Higgins et al., 2011).
All items from the Cochrane Risk of Bias tool were included.
TABLE 2 Demographic information for each study included in the systematic review

Total
sample
ROBINSON AND WADE

Study size Age (SD) N females Occupation Ethnicity Marital status SES
*Grieve et al., 2020 114 24.7 (8.4) 102 (89.5%) Tertiary students Asian (n = 28, 24.6%), U U
(n = 114) Australian (n = 71,
62.3%), other
(n = 15, 12.2%)
Goldstein et al., 2014 57 23.4 (7.1) 56 (98.2%) U U U U
*Handley et al., 2015 42 28.9 (8.3) 34 (81%) Student (n = 22), U U U
employed (n = 20)
Hurst & Zimmer- 3 16.7 (1) 3 (100%) U U U U
Gembeck, 2019
*Johnson et al., 2019 31 22.1 (5.5) 28 (90.3%) U Caucasian (n = 24, U U
77%), Asian (n = 3,
10%), other (n = 4,
13%)
*Kothari et al., 2019 120 28.9 (7.9) 98 (81.7%) Tertiary students White British (n = 52, Single (n = 88, 73%), U
(n = 62), vocational 44%), other (n = 66, married (n = 27,
certificate trained 56%) 22.5%), divorced
(n = 57) (n = 5, 4%)
Larsson et al., 2018 14 27.4 (7.7) 14 (100%) U U U U
Levinson et al., 2017 28 26.8 (12.6) U U European-American U U
(n = 20, 71%)
Lloyd et al., 2015 21 22 (U) U U U U U
*Shu et al., 2019 94 16.2 (1.8) 94 (100%) U U U U
*Steele & Wade, 2008 48 24.7 (5.5) 47 (97.9%) Tertiary student U Single (n = 28, 58.3%) U
(n = 16), employed
(n = 31)
Tchanturia et al., 2016 35 U U U U U U
*Valentine et al., 2018 67 37 (12) 41 (61.2%) U U U U
*Wade et al., 2019 66 26.7 (9.6) 56 (85.5%) U U U U
*Wilksch et al., 2008 138 15 (0.4) 138 (100%) High school students U N/A Middle income (private and
(n = 138) public schools assessed)

Note: Studies labeled with an asterisk signifies those included in the meta-analyses.
Abbreviations: SES, socioeconomic status; U, undisclosed information.
479
480 ROBINSON AND WADE

3 | RESULTS Across the nine studies 720 participants were included (88.6%
female sample) with the mean age of participants ranging from
3.1 | Systematic review 15–37 years old (total mean age = 24.9 years). More than half the
studies recruited through secondary or tertiary educational insti-
As shown in Figure 1, the search identified 881 studies with 28 studies tutes, resulting in a 48.9% (n = 352) student participant population.
identified as potentially relevant. From the grey literature search, one addi- Information was not routinely reported regarding marital status
tional unpublished study (currently under review for publication) was pro- (n = 2), socioeconomic status (n = 1), and ethnicity (n = 4). Where
vided by a contacted author. Fifteen studies were included for systematic this information was provided, participants were majority Cauca-
review and the study characteristics summarized in Table 1. Studies within sian (44–77%) and single (58–73%).
this broader category were published between 2008–2020 and included
eight randomized trials, five case series, one qualitative assessment, and
one non-randomized controlled comparison. Self-guided treatments 3.4 | Within group effect sizes
accounted for one-third (n = 5) of the programs whilst two-thirds (n = 10)
were guided by a clinician or researcher. All studies (where specified) pro- In order to account for the correlation between measures in a
vided cognitive behavioral therapy as the basis of the intervention. The pre-post sample, a correlation coefficient was applied to all
primary outcomes clustered around symptom reduction (ED: n = 4, perfec- within-group ES estimates. These correlations were: Perfection-
tionism: n = 6, ED and perfectionism: n = 1) and intervention feasibility ism, r = 0.394; ED, r = 0.643; Depression, r = 0.513; Anxiety,
(n = 4). Participants were recruited from ED outpatient services (n = 3), ED r = 0.394. As shown in Table 3, and Figures 2 and 3, perfection-
inpatient services (n = 3), and non-clinical settings (n = 9). Nine interven- ism interventions were associated with large and significant effect
tions were conducted face to face and six used an online format. size decreases in symptoms of perfectionism and disordered eat-
ing. Significant and moderate effect size decreases for symptoms
of depression and anxiety were observed (Figures S1 and S2).
3.2 | Meta analyses

Nine of the fifteen studies were selected for the meta-analysis. Five 3.5 | Between group effect sizes
studies were excluded for offering augmented or concurrent treat-
ment and one qualitative study was excluded. The final selection Displayed in Table 3, and Figures 4 and 5, perfectionism intervention
included one case series, one non-randomized controlled comparison, cohorts experienced significantly greater reductions in perfectionism
and seven randomized trials. and disordered eating compared to comparison groups. There was no
significant difference in symptoms of depression and anxiety when
compared to control condition cohorts (see Figures S3 and S4).
3.3 | Study characteristics Between-group results for disordered eating and perfectionism were
further investigated using post-hoc analyses. The between-group
Demographic information is provided in Table 2 and studies meta-analyses were split into several sub-groups in an attempt to
included in the meta-analysis are represented with an asterisk. reduce heterogeneity, these groups were: RCTs studies only (n = 6),

Pre-post trial comparison for Perfectionism: Perfectionism Intervention

Study name Statistics for each study Hedges's g and 95% CI
Hedges's Standard Lower Upper
g error Variance limit limit Z-Value p-Value
Grieve et al (2020) -0.733 0.172 0.029 -1.069 -0.397 -4.273 0.000
Handley et al (2015) -1.137 0.301 0.091 -1.728 -0.547 -3.776 0.000
Johnson et al (2019) -0.750 0.219 0.048 -1.180 -0.320 -3.418 0.001
Kothari et al (2019) -0.982 0.169 0.028 -1.313 -0.651 -5.818 0.000
Shu et al (2019) -1.056 0.226 0.051 -1.499 -0.614 -4.677 0.000
Steele et al (2008) -1.150 0.354 0.126 -1.845 -0.455 -3.244 0.001
Valentine et al (2018) -6.252 0.809 0.654 -7.837 -4.667 -7.731 0.000
Wade et al (2019) -1.459 0.295 0.087 -2.038 -0.881 -4.948 0.000
Wilksch et al (2008) -0.394 0.184 0.034 -0.756 -0.033 -2.141 0.032
-1.198 0.219 0.048 -1.628 -0.767 -5.457 0.000

-2.00 -1.00 0.00 1.00 2.00

Decrease Symptoms Increase Symptoms

Meta Analysis: Random Effects Model

FIGURE 2 Forest plot for pre-post perfectionism intervention effect on perfectionism symptoms
ROBINSON AND WADE 481

self-guided studies only (n = 5), online studies only (n = 5), and studies

Y intercept (p)
−7.590 (.041)
−7.555 (.065)
−7.349 (.068)
−1.757 (.490)
which used the EDE-Q (global) as a disordered eating measure (n = 6).

Egger's test
No significant or clinically relevant alterations came from these
attempts to subdivide the studies into more homogenous samples
(Figure S5).

77.875 (.00)
23.277 (.00)
5.485 (.36)
87.23 (.00)
3.6 | Heterogeneity
Q (p)
Heterogeneity

Significant heterogeneity was found across all analyses, ranging from

62–93%, except for between-group comparisons of anxiety. Q and I2

8.848
91.975
91.011
78.52
values are reported in Table 3.
I2

3.7 | Publication bias

−1.967, −0.589
−1.267, −0.013
−0.919, 0.025
−0.361, 0.081

Publication bias was present in all within-group analyses, as shown by

95% CI
Between-group (n = 8)

Egger's test in Table 3. Publication bias was not apparent for

between-group comparisons related to disordered eating, depression,
and anxiety but was evident for perfectionism. Due to the presence
Summary of effect sizes (and 95% confidence intervals) with Heterogeneity and Publication Bias (Egger's test)

Effect size

Hedge's g

of substantial heterogeneity, further analysis of publication bias

−1.278

−0.447
−0.140
−0.64

(i.e., the Trim and Fill approach by Duval and Tweedie) could not be
performed.
Y intercept (p)
−6.231 (.005)
−9.146 (.003)
−5.907 (.024)
−4.673 (.029)
Egger's test

3.8 | Quality assessment

Study quality was rated across nine items selected from the full Con-
sort 2010 checklist (see Table S1). The results of the first quality
assessment, addressing all studies included in the meta-analysis, are
58.164 (.00)

36.503 (.00)
18.852 (.01)
111.63 (.00)

summarized in Figure 6. The average number of items achieved (“Yes”

responses) for each study was six (range two to eight), the average
Q (p)

number of items not achieved (“No” responses) was two (range zero
Heterogeneity

to five). The only item unmet by the majority (>50%) of studies was
the inclusion of a baseline demographics table describing participants.
86.246
92.833
80.823
62.869

Age and gender were the only demographic factors routinely

I2

reported.
The Cochrane Risk of Bias (II) tool was applied to six RCTs
included in the meta-analysis. Of the six analyzed, one study received
−1.673, −0.789
−1.319, −0.506
−0.897, −0.314
−0.637 -0.188

an overall bias rating of “Low” and the remaining five were of “Some”
concern. The area of greatest concern, where risk of bias was rated as
95% CI

“High” for two of the six RCTs, was the handling of missing outcome
Within-group (n = 9)

data (See Figure S6).

Effect size

Hedge's g
−1.231
−0.913
−0.605
−0.413

4 | DI SCU SSION

The purpose of this review and meta-analysis was to assess studies

which used perfectionism interventions to impact upon symptoms of
Eating disorder
Perfectionism

perfectionism and disordered eating. For comparison with two previ-

Depression
Construct
TABLE 3

Anxiety

ous meta-analyses, this review analyzed both within-group and

between-group effect estimates to determine the efficacy of perfec-
tionism interventions for reducing perfectionism, disordered eating,
482 ROBINSON AND WADE

Pre-post trial comparison for Disordered Eating: Perfectionism Intervention

Study name Statistics for each study Hedges's g and 95% CI
Hedges's Standard Lower Upper
g error Variance limit limit Z-Value p-Value
Grieve et al (2020) -0.265 0.119 0.014 -0.498 -0.033 -2.234 0.025
Handley et al (2015) -0.545 0.191 0.037 -0.920 -0.171 -2.854 0.004
Johnson et al (2019) -1.440 0.214 0.046 -1.859 -1.021 -6.732 0.000
Kothari et al (2019) -0.423 0.111 0.012 -0.640 -0.206 -3.818 0.000
Shu et al (2019) -0.442 0.145 0.021 -0.725 -0.158 -3.054 0.002
Steele et al (2008) -0.578 0.225 0.051 -1.019 -0.138 -2.572 0.010
Valentine et al (2018) -4.395 0.447 0.199 -5.270 -3.519 -9.840 0.000
Wade et al (2019) -1.062 0.196 0.038 -1.447 -0.678 -5.416 0.000
Wilksch et al (2008) -0.233 0.138 0.019 -0.504 0.037 -1.691 0.091
-0.913 0.208 0.043 -1.319 -0.506 -4.397 0.000

-2.00 -1.00 0.00 1.00 2.00

Decrease Symptoms Increase Symptoms

Meta Analysis: Random Effects Model

FIGURE 3 Forest plot for pre-post perfectionism intervention effect on eating disorder and body image symptoms

Post-trial comparison for Perfectionism: Perfectionism Intervention vs Control Condition

Study name Statistics for each study Hedges's g and 95% CI

Hedges's Standard Lower Upper
g error Variance limit limit Z-Value p-Value
Grieve et al (2020) -0.419 0.210 0.044 -0.831 -0.007 -1.991 0.046
Handley et al (2015) -1.195 0.330 0.109 -1.841 -0.549 -3.625 0.000
Kothari et al (2019) -0.997 0.193 0.037 -1.374 -0.619 -5.175 0.000
Shu et al (2019) -0.656 0.267 0.071 -1.179 -0.132 -2.456 0.014
Steele et al (2008) -0.604 0.404 0.163 -1.396 0.187 -1.496 0.135
Valentine et al (2019) -7.528 0.766 0.586 -9.029 -6.028 -9.833 0.000
Wade et al (2019) -0.665 0.285 0.081 -1.224 -0.107 -2.337 0.019
Wilksch et al (2008) -0.359 0.236 0.056 -0.822 0.103 -1.524 0.128
-1.278 0.351 0.124 -1.967 -0.589 -3.637 0.000

-2.00 -1.00 0.00 1.00 2.00

Fav ours Interv ention Fav ours Control

Meta Analysis: Random Effects Model

FIGURE 4 Forest plot for perfectionism intervention between group effect on perfectionism symptoms

depression, and anxiety. The results indicate perfectionism interven- disordered eating symptoms could be reduced in a population diag-
tions were associated with a large effect for reducing perfectionism nosed with Bulimia Nervosa using a perfectionism intervention. This
and disordered eating (between-group and within-group analyses), updated analysis indicates disordered eating is responsive to perfec-
and a moderate effect for reducing depression and anxiety (within- tionism treatment in clinical and non-clinical populations.
group analyses only). These outcomes are consistent with the earlier Results from this review should be interpreted with caution as
findings by Lloyd et al. (2015) and Suh, Sohn, Kim, and Lee (2019) high heterogeneity was found across all analyses but one. Reasons for
who reported comparable ES estimates in their meta-analyses for heterogeneity were unable to be explored, through meta-regression,
depression, anxiety, and perfectionism. The results of this meta- due to the small sample size and lack of potential moderators reported
analysis built upon the suggestion from Lloyd et al. (2015) that within the selected studies. Attempts were made to reduce
ROBINSON AND WADE 483

Post-trial comparison for Disordered Eating: Perfectionism Intervention vs Control Condition

Study name Statistics for each study Hedges's g and 95% CI

Hedges's Standard Lower Upper
g error Variance limit limit Z-Value p-Value
Grieve et al (2020) -0.130 0.208 0.043 -0.538 0.278 -0.626 0.532
Handley et al (2015) -1.021 0.323 0.104 -1.653 -0.388 -3.163 0.002
Kothari et al (2019) -0.180 0.182 0.033 -0.536 0.177 -0.987 0.323
Shu et al (2019) -0.145 0.260 0.068 -0.655 0.366 -0.555 0.579
Steele et al (2008) -0.188 0.396 0.157 -0.963 0.588 -0.474 0.635
Valentine et al (2019) -4.106 0.473 0.224 -5.034 -3.178 -8.673 0.000
Wade et al (2019) -0.171 0.278 0.077 -0.715 0.373 -0.617 0.537
Wilksch et al (2008) 0.297 0.235 0.055 -0.164 0.758 1.264 0.206
-0.630 0.316 0.100 -1.249 -0.011 -1.995 0.046

-2.00 -1.00 0.00 1.00 2.00

Fav ours Interv ention Fav ours Control

Meta Analysis: Random Effects Model

FIGURE 5 Forest plot for perfectionism intervention between group effect on disordered eating symptoms

Ethical approval

Results including expressions of uncertainty

Number of participants included in analysis

Baseline demographic and clinical characteristics

Losses and exclusion after randomisation

Number of participants assessed, assigned, and treated

Rationale for numbers

Interventions for each group described with detail to allow

replication

Eligibility criteria for participants

0 10 20 30 40 50 60 70 80 90 100

Yes Partial No

FIGURE 6 Quality assessment by item expressed as percentages across all studies included in the meta-analysis

heterogeneity by subdividing the studies from the between-group were available for inclusion and variations existed in the studies'
meta-analyses into groups based on design, demographic, or outcome designs, interventions, outcome measures, and participant selection
variables. Heterogeneity remained high across all subdivided analyses. criteria. Target populations included a mix of elevated perfectionism,
Heterogeneity may result from statistical, clinical, or methodological elevated disordered eating/body image concerns, non-clinical/self-
factors, or the presence of publication bias (Fletcher, 2007). While identified perfectionists, and high school students with no clinically
Egger's test results indicate the presence of publication bias, these relevant traits. These variations suggest clinical heterogeneity may
findings are inconclusive unless all other reasons for possible hetero- have been a contributing factor, however, a greater number of studies
geneity can be excluded. Due to the nature of this review, few studies are needed to distinguish the cause or causes of heterogeneity and
484 ROBINSON AND WADE

whether publication bias was genuinely present. Despite this limita- disordered eating, rather than elevated perfectionism, as their primary
tion, this meta-analysis provides important early evidence as to the concern.
potential efficacy of perfectionism interventions as a transdiagnostic The results of the meta-analysis should be interpreted in the con-
treatment tool across a variety of participant demographics and study text of three important limitations. First, perfectionism was investi-
designs. Given the preliminary nature of these findings, understanding gated as a single outcome. Preference was given to analyzing the
the impact of moderators would provide a valuable addition to this FMPS-CM to allow for greater cross-study comparison, but in doing
research. Moderators may account for unexplained variance (hetero- so it limited which aspects of perfectionism were explored and pro-
geneity) and have clinical implications regarding to how to best imple- vided a unidimensional view of how perfectionism may respond to
ment perfectionism interventions to a targeted audience. Potential intervention. Future analyses may wish to take a more multi-
moderators for future investigation include: sex, age, duration of dis- dimensional approach when investigating perfectionism and to sepa-
ordered eating behaviors, clinical versus non-clinical groups, dimen- rately assess various components, particularly in instances where
sions of perfectionism experienced (PS, PC, or both), study design, multiple perfectionism measures are provided. Including multiple mea-
intervention modality, and study quality. sures will clarify which aspects of perfectionism are most responsive
One explanation for why perfectionism interventions appear to to treatment and help to identify which perfectionism measures corre-
have a greater impact on disordered eating than depression and anxi- late well with scores (and reductions) of disordered eating.
ety is that perfectionism does not impact on the latter to the same Second, the information presented in this meta-analysis regarding
extent as it does the former. It is likely the contribution of perfection- depression and anxiety was selected as a subsample from the total
ism to the development and maintenance of various psychopathol- information available on this topic and should therefore be interpreted
ogies is idiosyncratic. This notion is supported by Limburg et al. (2017) within this context. Only studies which assessed depression and anxi-
who demonstrated using path analysis that PC and PS were not ety along with a measure of disordered eating or body image concern
equally correlated with depression, anxiety, and eating disorders. Both were included in this review. A more accurate representation of the
dimensions of perfectionism uniquely explain disorder symptoms, between-group ES estimates can be found in the analysis by Suh
however, PS was shown to contribute minimally to depression and et al. (2019) who previously found a significant impact of perfection-
anxiety, and to correlate to a larger degree with Anorexia Nervosa ism interventions on reducing depression and anxiety in randomized
and Bulimia Nervosa. As perfectionism interventions reduce both control trials. The between-group estimates for depression and anxi-
dimensions of perfectionism (Suh et al., 2019), eating disorder symp- ety in the current study were weaker in comparison to the Suh
toms may reduce to a greater extent because a greater portion of the et al. (2019) study, potentially due to a lack of power. These estimates
contributing factors are being targeted. Alternatively, perfectionism should be considered only as comparators for within this study, and
may impact a wider and more diverse range of components in disor- not as absolute values which fully account for the effect of perfec-
dered eating than in depression or anxiety. Perfectionism may serve tionism interventions on symptoms of depression and anxiety.
to maintain disordered eating through perfectionistic standards being Third, within-group ES estimates, while providing a useful com-
applied to multiple areas such as exercise (i.e., completing the perfect parison to previous meta-analyses (Lloyd et al., 2015), tend to be less
number of hours or intensity of exercise), diet (i.e., eating to a perfect reliable than between-group ES estimates. Within-group analyses are
meal plan or calorie intake) and appearance or the overvaluation of limited by the absence of a control group comparator and are affected
shape and weight (Smith et al., 2007; Watson et al., 2011). by the association between pre- and post-trial data. To account for
Perfectionism appears as a key transdiagnostic component in these limitations, both between-group and within-group ES estimates
models of eating disorders that have influenced effective treatment have been provided for this meta-analysis, and the relationship
development (Fairburn, Cooper, & Shafran, 2003; Pennesi & between pre-post data was accounted for using estimated correlation
Wade, 2016; Schmidt, Wade, & Treasure, 2014). The greater influence coefficients (r). Ideally, correlation coefficients should be calculated
of perfectionism interventions on disordered eating may have implica- for each study to ensure accuracy of the ES estimates. Correlation
tions for improving the efficacy of treatment in eating disorders. Per- coefficients, however, were not reported for most studies. Conse-
fectionism interventions are viewed as a valuable adjunct to therapy quently, next best practice was employed (Cuijpers, Weitz, Cristea, &
for eating disorders (Fairburn et al., 2009; Hurst & Zimmer- Twisk, 2017) which was to estimate the correlation coefficient for
Gembeck, 2019). Whether treatment for eating disorders may benefit each construct using previous research by Shafran et al. (2017). Using
from the routine inclusion of a perfectionism component (irrespective an estimate from a single study introduces biases such that missing
of whether perfectionism is an identified issue) is a question that data in the Shafran et al. dataset likely impacted the within-group ES
needs to be addressed in future research. The findings from this estimates. Future studies should consider routinely reporting the cor-
meta-analysis indicate perfectionism interventions may effectively relation coefficient (r) to allow for accurate calculations of ES esti-
reduce disordered eating symptoms in populations who are not char- mates in within-group analyses.
acterized by high levels of perfectionism. This conclusion, however, This meta-analysis summarizes the available information regard-
was based on divided evidence from three studies (Johnson ing the impact of perfectionism interventions on disordered eating
et al., 2019; Steele & Wade, 2008; Wilksch et al., 2008) and further and body image concerns. Following this review, a number of sugges-
investigation is needed with studies targeting populations with tions have been proposed as guidance for future research in this area.
ROBINSON AND WADE 485

First, little information is available as to the effect of perfectionism DATA AVAILABILITY STAT EMEN T
interventions on clinical populations. Since Lloyd et al.'s, 2015 review, The data that support the findings of this study are available from the
a single study has been produced which investigated a target popula- corresponding author upon reasonable request.
tion with body image concerns (Johnson et al., 2019). Yet unlike its
predecessor (Steele & Wade, 2008), this study did not require partici- OR CID
pants to meet the full diagnostic criteria for an eating disorder. This Katherine Robinson [Link]
lack of current evidence highlights the need for future research to Tracey D. Wade [Link]
focus on the use of perfectionism interventions in clinical populations.
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