Are attachment styles differentially related to interpersonal perfectionism and

binge eating symptoms?

Liesbet Boone
,1
Department of Developmental, Social, and Personality Psychology, Ghent University, Belgium
a r t i c l e i n f o
Article history:
Received 31 July 2012
Received in revised form 15 January 2013
Accepted 21 January 2013
Available online 21 February 2013
Keywords:
Attachment
Adolescence
Interpersonal perfectionism
Binge eating symptoms
a b s t r a c t
In the current study we aimed to examine the association between attachment styles towards father and
mother, perfectionistic self-promotion (PSP), socially prescribed perfectionism (SPP), and binge eating
symptoms in a sample of 328 late adolescents (mean age 17.1 years). It was examined whether anxiously
and avoidantly attached adolescents would differentially cope with their insecure feelings. It was hypoth-
esized that anxiously attached adolescents would, through hyperactivating strategies, be hypersensitive
to the expectations of others. Avoidantly attached adolescents were hypothesized to present a perfect
image of the self, because of their deactivating emotion regulation. Furthermore, the mediating role of
perfectionism in the relation between attachment representations and binge eating symptoms was
examined. Results showed that anxious attachment was signicantly positively associated with PSP,
SPP, and binge eating. Avoidant attachment towards mother was only positively associated with SPP,
whereas avoidant attachment towards father was positively associated with PSP and binge eating. PSP
fully mediated the relation between avoidant attachment towards father and binge eating. Interestingly,
the current ndings showed the importance of examining attachment representations towards both
parents.
2013 Published by Elsevier Ltd.
1. Introduction
Bowlbys attachment theory (Bowlby, 1982/1969) is one of the
most prominent and useful frameworks to conceptualize the rela-
tionship between parents and children and to understand the pro-
cess of affect regulation (Mikulincer, Shaver, & Pereg, 2003).
Attachment theorystates that, onthe basis of earlyinteractions with
attachment gures, children develop secure or insecure attachment
representations. According to the model of Mikulincer and Shaver
(2007), attachment styles are conceptualized as regions in a two-
dimensional space. These dimensions are referred to as attachment
anxiety and attachment avoidance. Individuals scoring high on one
of these dimensions are said to be insecurely attached. Individuals
scoring lowonbothattachment anxiety andavoidance are calledse-
curely attached individuals. Individuals scoring high on anxious
attachment are preoccupied with fear of interpersonal rejection or
abandonment and use more hyperactivating strategies, whereas
individuals scoringhighonavoidanceattachment aremorepreoccu-
pied with fear of interpersonal closeness or independence and make
more use of deactivating strategies to regulate stress and emotions
(Mikulincer et al., 2003). Hyperactivating strategies are character-
izedby constant vigilance, concern, andeffort to reestablishproxim-
ity, involvement and care from the attachment gure. These
strategies typically involve clinging and dependent behavior, and
feelings of helplessness and incompetence in regulating ones affect.
Deactivating strategies are characterized by the attempt to regulate
distress alone, in which closeness, intimacy and dependence on oth-
ers is totally denied. By striving for self-reliance and independence,
avoidantly attached individuals tried to avoid frustration and dis-
tress when the attachment gure was not available. Although both
hyperactivating and deactivating strategies may have a function in
coping with emotional stress, they are maladaptive secondary emo-
tion regulation strategies (Mikulincer et al., 2003) and have been
found to be associated with psychopathology (e.g., Brenning, Soen-
ens, Braet, & Bosmans, 2012).
Attachment insecurity has been linked to both perfectionism
(Rice & Mirzadeh, 2000) and eating disorder (ED) pathology (Ward,
Ramsay, & Treasure, 2000). Research has shown that adolescents
who are avoidantly and anxiously attached were more self-critical
and had higher levels of evaluative concerns perfectionism(Thomp-
son & Zuroff, 1999; Wei, Heppner, Russell, & Young, 2006). With re-
gard to ED symptoms, several studies found that insecure
attachment was more prevalent in EDpopulations than in non-clin-
ical samples (Zachrisson & Skarderud, 2010). ColeDetke and Kobak
(1996) found that women with deactivating strategies were more
prone to report elevated levels of ED symptoms. In a recent study
among adolescents, it was found that insecure attachment was pos-
0191-8869/$ - see front matter 2013 Published by Elsevier Ltd.
http://dx.doi.org/10.1016/j.paid.2013.01.006

Address: Department of Developmental, Social, and Personality Psychology,

Henri Dunantlaan, 2 B-9000 Ghent, Belgium. Tel.: +32 (0) 9 264 64 86; fax: +32 (0) 9
264 64 99.
E-mail address: Liesbet.Boone@UGent.be
1
The author is research assistant at the Fund for Scientic Research - Flanders
(FWO).
Personality and Individual Differences 54 (2013) 931935
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j our nal homepage: www. el sevi er . com/ l ocat e/ pai d
itively associated withbinge symptoms in female adolescents (Pace,
Cacioppo, & Schimmenti, 2012).
Binge eating symptoms (uncontrollable eating of a large amount
of food in a short period of time) are highly prevalent in adolescent
boys and girls (Abebe, Lien, Torgersen, &von Soest, 2012). Binge eat-
ing is found to occur in response to excessive dieting (Fairburn, Coo-
per, &Shafran, 2003) or to act as a compensatory mechanismto cope
withor toescape fromnegative feelings (Spoor, Bekker, VanStrien, &
van Heck, 2007). Consistent with the latter theory, binge eating
serves the function of maladaptive emotion regulation, such as
avoidant coping. Indeed, it has beenfoundthat eatingdisorderedpa-
tients typicallyhavepoor emotionrecognitionandregulationcapac-
ities (Harrison, Sullivan, Tchanturia, & Treasure, 2009).
An extensive body of research has shown that avoidant attach-
ment is strongly related with a self-critical personality style and
depression (Blatt, 2004). Self-critical individuals are preoccupied
withthemes suchas self-denitionandself-worth, andtendtofocus
solely on achievement and control, at the expense of interpersonal
relationships (Blatt, 2004). However, less research investigated the
role of more interpersonal aspects of perfectionism, such as perfec-
tionistic self-promotion and socially prescribed perfectionism.
On the basis of Mikulincer and Shavers model of emotion regula-
tion (Shaver & Mikulincer, 2002), it could be hypothesized that avoi-
dantly and anxiously attached individuals will differentially cope
withdistress. It couldbeexpectedthat anxiouslyattachedindividuals
hyperactivating strategies will drive them to try to attain to the per-
ceivedstandardsfromothers (sociallyprescribedperfectionism) inor-
der to gain or maintain others love and approval. Avoidant peoples
deactivating strategies are hypothesized to incline themtowards the
setting of high standards for themselves (perfectionistic self-promo-
tion) in order to appear perfect and independent, and to defensively
maintain a sense of superiority. Indeed, perfectionistic self-presenta-
tion has been described as a defensive coping strategy that is used to
deal with a threatened viewof the self, and ineffectively tries to build
up or maintain a positive view of the self (Hewitt et al., 2003).
1.1. The present study
In this study, our aims were two-fold. First, in a non-clinical sam-
ple of adolescent males and females we aimed to examine whether
attachment styles (avoidant, anxious, and secure attachment) were
differentially relatedto perfectionistic self-promotion(PSP), socially
prescribed perfectionism(SPP), and binge eating symptoms. On the
basis of Mikulincer andShavers model of emotionregulation, weex-
pected that anxious attachment will be uniquely associated with
SPP, whereas avoidant attachment will be uniquely associated with
PSP. Secure attachment is expected to be negatively associated with
both perfectionism components. Insecure attachment is hypothe-
sized to be positively related to binge eating, whereas the inverse
relationfor secure attachment was expected(Wardet al., 2000). Sec-
ond, a mediating model was tested in which it was examined
whether SPP and PSP can explain why respectively anxious and
avoidant attachment are related to binge eating symptoms. More-
over, since the majority of research on attachment only focusses
on attachment towards the mother and previous research showed
that also fathers play animportant role inattachment andbinge eat-
ing (Pace et al., 2012), attachment styles were assessed with regard
to both parents.
2. Method
2.1. Participants and procedure
A total of 328 late-adolescent females (57%) and males (43%),
with a mean age of 17.1 years (SD = 1.13, range = 1420) from
two high schools in Belgium participated in the study. Males and
females did not differ in age (t (325) = 1.68, p > .05), but males
tended to have a higher adjusted BMI compared to females (t
(313) = 5.43, p < .001). All participants were Caucasian, following
the academic track, and came from middle-class backgrounds. Of
the participants, 78% came from intact, two parent families, 20%
had divorced parents, 2% came from a family in which one of the
parents had died. We obtained passive informed consents from
parents and active written assent from the adolescents. Adoles-
cents got the opportunity to withhold participation at any moment
during the assessment. The response rate to participate in the
study was 82%.
2.2. Instruments
2.2.1. Attachment
Insecure attachment styles were measured using the Experi-
ences in Close Relationships Scale (ECR-R; Fraley, Waller, & Bren-
nan, 2000). The ECR-R consists of 36-items (rated on a 7-point
Likert scale) and measures attachment anxiety and avoidance.
The ECR-R is a generic measure of relationships, allowing one to
use its items to ask for different types of relationships. In this
study, attachment representations towards mother and father
were asked separately, and measures were not counterbalanced.
The ECR-R has been found to show good psychometric properties
(Fraley et al., 2000). Secure attachment towards mother and father
was measured using the subscale trust of the People in my Life
(PIML; Cook, Greenberg, & Kusche, 1995). This subscale contains
10-items, with scores ranging from 1 to 4. The PIML is designed
to measure childrens representations of their relationship with
parents, peers, and teachers and has good psychometric properties
(Murray & Greenberg, 2006).
2.2.2. Perfectionism
From the Perfectionistic Self-presentation Scale (PSPS; Hewitt
et al., 2003), the 10-item subscale Perfectionistic self-promotion
(PSP) was used to measure the attempt to which a person demon-
strates ones supposed perfection to others by actively and unreal-
istically presenting ones positive abilities, accomplishments, and
successes. This scale is rated on a 7-points Likert scale and has been
proven to be a valid and reliable measure (Hewitt et al., 2003). So-
cially prescribed perfectionism (SPP) was measured using the mul-
tidimensional perfectionism of Hewitt and Flett (MPS-H&F; Hewitt
& Flett, 1991). The subscale SPP is a subscale of the MPS, assessing
the extent to which people believe that others have unrealistic
standards for them, evaluate them stringently, and exert pressure
on them to perform perfectly. This subscale contains 15 items,
scored on a 7-points Likert scale, and has been shown to have good
psychometric properties (Hewitt & Flett, 1991).
2.2.3. Binge eating symptoms
Binge eating symptoms were measured using the bulimia scale
of the eating disorder inventory II (Garner, 1991). This subscale
contains 8 items, assessing binge eating and purging. Because only
one item measures purging behavior, this item was deleted, result-
ing in a 7-point scale measuring binge eating symptoms (see also
Boone et al., 2012).
2.3. Analyses
First, to test for differences between gender among the study
variables, a single ANOVA was performed with gender as indepen-
dent variable and the study variables as dependent variables. Sec-
ond, to investigate the associations between the background
variables and the study variables, zero-order correlations were cal-
culated. Third, to examine the mediating role of perfectionism
932 L. Boone / Personality and Individual Differences 54 (2013) 931935
components between attachment styles and binge eating, we fol-
lowed the four step procedure of Kenny, Kashy, and Bolger
(1998), controlling for age, gender, adjusted BMI, and family status.
According to the four step procedure, conditions in all paths should
be met to show mediation. Step 1 requires a signicant path from
the independent variable (attachment) to the dependent variable
(binge eating). Step 2 involves a signicant path from the indepen-
dent variable to the mediating variable (PSP and SPP). Step 3 re-
quires nding a signicant path from the mediating to the
dependent variable, controlling for the independent variable. Final-
ly, step 4, mediation is shown when the initial signicant effect of
the independent variable on the dependent variable is reduced to
non-signicance after controlling for the mediator.
3. Results
3.1. Preliminary Results
Single ANOVAs revealedthat gender differences were signicant
for attachment avoidance towards mother (F(1, 325) = 17.47,
p < .001), attachment avoidance (F(1, 317) = 4.99, p < .05) andsecure
attachment (F(1, 318) = 5.41, p < .05) towards father, and binge eat-
ing symptoms (F(1, 324) = 10.92, p < .01). Boys reported more avoid-
ant attachment towards mother and more secure attachment
towards father compared to girls, whereas girls reported more
avoidant attachment towards father and more binge eating symp-
toms compared to boys. Furthermore, we have looked at whether
gender moderated the effects of insecure and secure attachment in
the prediction of PSPS, PS, and binge eating. However, none of these
interaction terms were signicant (above and beyond the main ef-
fects of attachment and gender), suggesting that the effects of
attachment to the mother and father were not stronger for girls
and boys respectively (i.e., same-sex linkage hypothesis; Cassidy,
1990). Family status had signicant effects on trust towards mother
(F(2, 320) = 4.92, p < .01) and father (F(2, 313) = 3.94, p < .05), avoid-
ance (F(2, 312) = 8.91, p < .001) and anxiety (F(1, 314) = 7.47, p < .01)
towards father. Adolescents from an intact family reported most
trust, and least avoidant and anxious attachment, whereas adoles-
cents for whom one of the parents died reported the least trust,
and the most avoidant and anxious attachment towards the father.
Zero-order correlations between the attachment styles towards
father and mother, perfectionism components and binge eating are
shown in Table 1. Anxious attachment towards mother and father
was signicantly positively associated with PSP, SPP, and binge eat-
ing. Avoidant attachment towards mother was only positively asso-
ciated with SPP, whereas avoidant attachment towards father was
positively associated with PSP and binge eating
2
. Secure attachment
towards both mother and father was negatively associated with both
perfectionism components and binge eating.
3.2. Mediating role of socially prescribed perfectionism in the relation
between attachment style and binge eating symptoms
As can be seen in Table 2, controlling for background variables,
in the rst three steps, path coefcients for attachment anxiety to-
wards mother and father, avoidant attachment towards mother,
and secure attachment towards mother and father were signi-
cant. When entering SPP at step 4, the path coefcients of the
attachment representations and binge eating were reduced signif-
icantly. For avoidant attachment towards mother, the coefcient
became non-signicant. Sobel tests (1982) were all signicant
and bias-corrected and accelerated (BCa) condence intervals
(95%) did not contain zero (Preacher & Hayes, 2004), showing that
the indirect effects of these attachment representations to binge
eating were signicant. Although SPP fully mediated the relation
between attachment avoidance towards mother and binge eating,
this indirect effect was rather small.
3.3. Mediating role of perfectionistic self-promotion in the relation
between attachment style and binge eating symptoms
As can be seen in Table 2, controlling for background variables,
in the rst three steps, path coefcients for attachment anxiety to-
wards mother and father, avoidant attachment towards father and
secure attachment towards mother and father were signicant.
When entering PSP at step 4, the path coefcient of the avoidant
attachment and binge eating was reduced to non-signicance.
For the other four paths, the path coefcients of the attachment
representations were reduced signicantly. Sobel tests were all sig-
nicant and bias-corrected and accelerated (BCa) condence inter-
vals (95%) did not contain zero, showing that the indirect effects of
these attachment representations to binge eating were signicant.
Only the indirect effect of secure attachment towards mother on
binge eating was rather small.
4. Discussion
Because previous studies never looked at the association be-
tween interpersonal perfectionism and binge eating (e.g., Hewitt,
Flett, & Ediger, 1995) in relation to attachment representations,
this was the aim of the current study.
As predicted, we found evidence for SPP to be strongly associ-
ated with anxious attachment towards both parents. There was a
less strong, but signicant association between SPP and avoidant
attachment towards the mother. PSP was only associated with
attachment avoidance towards father, and not to the mother. Con-
trary to our hypothesis, but in line with a recent study of Chen and
colleagues (2012) PSP was associated with anxious attachment to-
wards both father and mother. Our correlational ndings did thus
not provide overall evidence for the differential association be-
tween anxious attachment and avoidant attachment with SPP
and PSP respectively.
First, it seemed that anxious attachment was more strongly re-
lated to both perfectionism components compared to avoidant
attachment. These ndings suggest that anxiously attached adoles-
cents tend to have a stronger need to appear perfect and to attain
to others expectancies compared to avoidantly attached adoles-
cents. Given that anxiously attached individuals are typically char-
acterized by a strong desire for closeness and use clinging and
proximity seeking behaviors to deal with insecurity and distress,
it is somewhat surprising that it was also strongly related to PSP.
A possible explanation for this nding might be that adolescents
who desire closeness might try to mask their distress and insecu-
rity by showing others how perfect they are. Impressing others
might then be the coping strategy by which they aim to gain love
and approval from others and to avoid further disapproval or
shame (Flett, Hewitt, Oliver, & MacDonald, 2002). Indeed, children
with an attachment history of conditional approval may have
learned that only when one is perfect external approval and love
is granted (Hamachek, 1978). Anxious attachment has indeed been
linked to an attachment history characterized by conditional ap-
proval (Park, Crocker, & Mickelson, 2004). It thus appears that anx-
iously attached individuals may not only try to attain to the
perceived standards and expectations of others (SPP) in an attempt
to gain others love and approval, but may also engage in defensive
self-ination and try to impress others by appearing perfect.
2
Supplementary analyses showed that adolescents who were anxiously attached
to only one parent experienced less perfectionism and binge eating compared to
those adolescents who were anxiously attached to both parents. For avoidant
attachment, no such differences were found.
L. Boone / Personality and Individual Differences 54 (2013) 931935 933
Second, the association between avoidant attachment and SPP
on the one hand and PSP on the other hand depended on the
attachment gure. As expected, we found that avoidant attach-
ment towards father was related to PSP. Adolescents who were
avoidantly attached to their father, appeared to have an excessive
need to present themselves as perfect, which might be seen as a
deactivating strategy to cope with feelings of vulnerability and dis-
tress (Mikulincer et al., 2003). Since most of the studies on attach-
ment only focused on the role of the mother at the expense of the
fathers (Lamb, 2010), it is interesting to see that this association
only appeared to be true for the attachment towards fathers. Unex-
pectedly, avoidant attachment towards mother was related to SPP,
suggesting that adolescents who feel threatened by attachment
closeness with and dependence of the mother, hold the belief that
others have high standards and expectations. Possibly, these ado-
lescents who do not perceive their mother as a valuable option
to regulate and manage distress, might compensate for these feel-
ings by trying to attain to the expectations of others in order to
gain others love and approval.
With regard to binge eating, it was found that all insecure
attachment representations, except attachment avoidance towards
mother, were positively associated with binge eating. The associa-
tion between insecure attachment and binge eating is in line with
previous research (e.g., Ward et al., 2000) and stresses the impor-
tance of the role of the father in attachment and ED symptoms
(Bosmans, Goossens, & Braet, 2009).
Third, as expected, adolescents who were securely attached
experienced less SPP, PSP, and binge eating. This shows that secure
attachment might be considered as a protective factor for the
development of perfectionism and binge eating. Indeed, adoles-
cents with a secure base have internalized their attachment gure
and developed good emotion regulation strategies to cope with
stress, making them more resilient (Mikulincer et al., 2003).
The fourth aim of this study was to examine whether the inter-
personal perfectionism components would mediate between
attachment representations and binge eating. It was found that
SPP and PSP partially mediated the relation between attachment
anxiety and secure attachment towards father and mother. Inter-
estingly, PSP appeared to fully explain the relation between attach-
ment avoidance towards the father and binge eating. This nding
again stresses the importance of the attachment representation
of adolescents to their father for the experience of ED symptoms.
Adolescents who did not perceive their father as a safe haven in
times of distress, might compensate for these feelings by creating
Table 1
Reliability, means, standard deviations, and correlations of the study variables.
1 2 3 4 5 6 7 8 9 10 11
1. Age
2. Adjusted BMI .07
3. Anxiety_mother .11 .03
4. Avoidant_mother .06 .03 .40
***
5. Trust_mother .01 .03 .51
***
.70
***
6. Anxiety_father .06 .15
*
.53
***
.21
***
.40
***
7. Avoidant_father .09 .10 .21
***
.43
***
.32
***
.36
***
8. Trust_father .14
*
.07 .30
***
.29
***
.47
***
.46
***
.76
***
9. Perfectionistic self-promotion .16
**
.02 .25
***
.11 .14
*
.27
***
.19
**
.20
***
10. Socialy prescribed perfectionism .15
**
.08 .39
***
.12
*
.21
***
.34
***
.11 .17
**
.44
***
11. Binge eating symptoms .09 .10 .31
***
.07 .17
**
.27
***
.17
**
.25
***
.30
***
.34
***
a .90 .94 .91 .91 .93 .94 .87 .78 .75
Mean 17.06 98.24 2.11 3.35 3.34 2.31 2.87 3.15 3.45 3.25 2.19
Standard deviation 1.13 12.29 0.93 1.29 0.59 1.05 1.28 0.73 1.15 0.76 0.88
Note: Adjusted Body Mass Index (BMI) = [(actual BMI/percentile 50 of BMI for age and gender) 100].
*
p < .05.
**
p < .01.
***
p < .001.
Table 2
Mediation analyses with standardized betas for socially prescribed perfectionism (SPP) and perfectionistic self-promotion (PSP) as mediating variables between attachment styles
and binge eating, controlling for the effects of gender, age, adjusted BMI, and family status.
Step 1 Step 2 Step 3 Step 4 Sobel BCa 95% CI indirect effect(lower and upper) R- Square full model
Mediator SPP
Anxiety_mother .33
***
.36
***
.23
***
.24
***
4.55
***
.0390 .1381 .21
***
Avoidance_mother .13
*
.13
*
.31
***
.09 2.10
*
.0028 .0688 .17
***
Trust_mother .20
***
.21
***
.30
***
.14
*
3.12
***
.1752 .0376 .18
***
Anxiety_father .29
***
.34
***
.26
***
.21
***
4.28
***
.0340 .1272 .20
***
Avoidance_father .15
*
.10 .31
***
.12
*
1.62

.0055 .0559 .18

***
Trust_father .23
***
.15
*
.30
***
.19
**
2.34
*
.1178 .0146 .19
***
Mediator PSP
Anxiety_mother .32
***
.24
***
.23
***
.27
***
3.39
***
.0212 .0972 .21
***
Avoidance_mother .13
*
.11 .28
***
.10 1.78

.0003 .0571 .17

***
Trust_mother .20
**
.13
*
.27
***
.16
**
2.11
*
.1214 .0098 .17
***
Anxiety_father .29
***
.28
***
.23
***
.23
***
3.62
***
.0226 .1006 .19
***
Avoidance_father 15
**
.20
**
.28
***
.10 2.92
***
.0130 .0774 .15
***
Trust_father .23
***
.20
**
.26
***
.18
**
2.89
***
.1275 .0211 .17
***
Note: Step 1 = path from independent (attachment) to dependent variable (binge eating). Step 2 = path from independent to mediating variable (SPP or PSP). Step 3 = path
from mediating to dependent variable (controlling for the independent variable). Step 4 = path from independent to dependent variable (controlling for the mediator).
BCa = bias-corrected and accelerated (BCa); 1000 bootstrap samples.

p < .10.
*
p < .05.
**
p < .01.
***
p < .001.
934 L. Boone / Personality and Individual Differences 54 (2013) 931935
a perfect image of the self towards others. This maladaptive way of
coping with feelings and distress might further lead to binge eating
symptoms (Spoor et al., 2007). A second full mediating effect ap-
peared for SPP as mediator in the relation between attachment
avoidance towards mother and binge eating. However, it should
be noted that the indirect effect of this mediation effect was rather
small, which was due to a small effect of attachment avoidance on
binge eating.
4.1. Limitations and directions for future research
The present study had some limitations. First, the study was
cross-sectional in nature, which limits the interpretation of the
direction of effects. Although a mediation model was tested in
which directions of effects were suggested, we should be careful
with the interpretation of these ndings. Given that recent re-
search showed that there exists not only signicant between-per-
son but also within-person variability in attachment (Dunkley,
Berg, & Zuroff, 2012) and perfectionism (Boone et al., 2012), more
dynamic and bidirectional relations may occur. It would be inter-
esting for future research to examine dynamic associations be-
tween attachment representations and perfectionism, especially
because it has been found that perfectionists have interpersonal
difculties and experience more social disconnection (Chen et al.,
2012). Second, because our ndings are based entirely on self-re-
port measures our obtained associations might be inated because
of shared method variance. Future studies may want to use other
methods to measure attachment, such as observational measures
or interview-based measures.
4.2. Implications for treatment
Our ndings pointed to the importance to target both attach-
ment insecurity and maladaptive perfectionism in prevention or
treatment programs for adolescents with binge eating symptoms.
Although attachment-based family therapy has been found to be
successful in promoting adolescent-parent reattachment (Dia-
mond, Diamond, & Hogue, 2007), this programhas not yet been ap-
plied to the treatment of eating problems. On the basis of our
ndings, perfectionism seems to be another important factor to
target in treatment. Given that it was hypothesized that adoles-
cents engage in perfectionism as a maladaptive coping strategy
and ED patients are found to have poor emotion regulation strate-
gies (Harrison et al., 2009), treatment may also focus on coping,
emotion regulation, and mentalization (Allen, Fonagy, & Bateman,
2008).
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