RESEARCH ARTICLE

The Scars of the Inner Critic: Perfectionism and Nonsuicidal

Self-Injury in Eating Disorders
Laurence Claes1*, Bart Soenens2, Maarten Vansteenkiste2 & Walter Vandereycken1
1
2

Department of Psychology, Catholic University of Leuven, Belgium

Department of Psychology, University of Gent, Belgium

Abstract
Nonsuicidal self-injury (NSSI) is quite common in eating disorder (ED) patients and we wondered whether this combined self-harming
behaviour is related to perfectionism, a feature often found in ED patients. In addition, we examined associations between perfectionism
and functions underlying NSSI and the possible mediating role of intrapersonal perfectionism in the association between perceived parental criticism and NSSI. In a sample of 95 ED patients, 38.9% reported at least one type of NSSI, and this subgroup reported signicantly higher levels of parental criticism and evaluative concerns perfectionism (ECP) compared with ED patients without NSSI. ECP was
positively related to the self-punishment and cry-for-help functions of NSSI. Finally, ECP was found to mediate the association between
parental criticism and NSSI symptoms. Directions for future research and practical implications are discussed. Copyright 2011 John
Wiley & Sons, Ltd and Eating Disorders Association.
Keywords
perfectionism; parental criticism; eating disorders; nonsuicidal self-injury
*Correspondence
Laurence Claes, Department of Psychology, Catholic University of Leuven, Tiensestraat 102, 3000 Leuven, Belgium.
E-mail: Laurence.claes@psy.kuleuven.be

Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.1158

Nonsuicidal self-injury (NSSI) refers to any socially unaccepted

behaviour involving deliberate and direct destruction of ones
own body surface without suicidal intent, such as cutting, carving
and burning of the skin (Claes & Vandereycken, 2007). Eating
disorder (ED) patients display rather high rates of NSSI (Svirko
& Hawton, 2007), and this association appears to be linked to
higher levels of traumatic experiences and more comorbidity,
compared with ED patients without NSSI (Claes, Vandereycken
& Vertommen, 2003; Favaro & Santonastaso, 1998). Furthermore, there seems to exist a balance between both types of selfharming behaviours, such that losing control in one domain
requires compensation in the other domain (Muehlenkamp
et al., 2009). Prior work suggests that patients engage in NSSI
and/or ED mainly for the purposes of emotion regulation or social communication (Claes, Klonsky, Muehlenkamp, Kuppens &
Vandereycken, 2010; Glassman, Weierich, Hooley, Deliberto &
Nock, 2007; Svirko & Hawton, 2007).
Research evaluating personality risk factors for NSSI in ED
patients has typically focused on undercontrolled personality
features such as impulsiveness (Claes et al., 2010; Favaro &
Santonastaso, 1998, 2000), at the expense of a focus on relatively more overcontrolled and restrictive personality features
such as perfectionism. This is unfortunate because perfectionism is a particularly relevant trait to examine in association
with NSSI (Hoff & Muehlenkamp, 2009). For instance,
research has documented consistent associations between perfectionism and suicidal ideation and suicide attempts (Blatt,
Eur. Eat. Disorders Rev. (2011) 2011 John Wiley & Sons, Ltd and Eating Disorders Association.

1995; OConnor, Rasmussen & Hawton, 2010). Research also

shows that NSSI and suicidal ideation are strongly intertwined
(Joiner, 2006). These two independent research lines suggest,
at least indirectly, that perfectionism may play a role in NSSI
(Hoff & Muehlenkamp, 2009).
Perfectionism and nonsuicidal self-injury
In recent research, perfectionism is conceptualised as a complex and
multidimensional construct (Frost, Marten, Lahart & Rosenblate,
1990; Hewitt & Flett, 1991), comprising both maladaptive and
relatively more adaptive dimensions. Factor analyses performed
on the subscales of the most widely used instruments to assess
perfectionismthe Multidimensional Perfectionism Scales of
Hewitt & Flett (1991) and Frost et al. (1990)have consistently
yielded two factors in community and clinical samples: personal
standards perfectionism (PSP) and evaluative concerns perfectionism (ECP) (Dunkley, Blankstein, Masheb & Grilo, 2006). PSP
involves the setting of high standards and goals for oneself. However, it does not necessarily render people vulnerable to psychopathology and may even foster positive and goal-oriented striving
(Stoeber & Otto, 2006). ECP involves the tendency to be concerned
about making mistakes when trying to attain personal standards
(PS), to continuously doubt about whether behaviours meet expectations and to engage in self-derogation and self-criticism when
failing to live up to ones PS (Frost et al., 1990). These negative
self-evaluations would render individuals vulnerable to maladjustment in general and to internalising problems in particular.

The Scars of the Inner Critic

Research has indeed shown strong and consistent associations

between ECP and psychopathology, such as depression, anxiety
and low self-esteem (Dunkley et al; Dunkley, Sanislow, Grilo &
McGlashan, 2006 Soenens et al., 2008).
Past research has documented an association between perfectionism and NSSI in community samples. Some of these
studies (Glassman et al., 2007; Wedig & Nock, 2007) focused
on self-criticisma personality feature akin to evaluative
concerns perfectionismand indeed found evidence for a robust association with NSSI. At least one study to date used a
multidimensional measure of perfectionism in the context of
NSSI. Hoff and Muehlenkamp (2009) compared college students with and without a history of NSSI on the Frost
Multidimensional Perfectionism Scale. The NSSI group scored
signicantly higher than controls on one specic component
of intrapersonal perfectionism: concern over mistakes (CM),
one of the key indicators of ECP (Frost, Heimberg, Holt,
Mattia & Neubauer, 1993). Hence, this study suggests that
only ECP (and not PSP) is related to NSSI. However, more research is needed to address the relative contribution of both
perfectionism components in the prediction of NSSI.
To the best of our knowledge, no study has examined the associations between perfectionism and NSSI in clinical populations.
ED patients demonstrate elevated levels of perfectionism (ECP
in particular) compared with both normal controls and general
psychiatric samples (Bulik et al., 2003). Because they also show
a high prevalence of NSSI, we decided to study the association between NSSI and perfectionism in a sample of ED patients.
Perfectionism and functions of nonsuicidal
self-injury
The second aim of this study was to gain more insight in the dynamics involved in the link between perfectionism and NSSI. In
our view, there are at least two reasons why perfectionism might
be related to NSSI. First, perfectionism (ECP in particular) is
strongly related to negative affectivity, including depressed mood
and anxiety (Dunkley, Blankstein, et al., 2006; Dunkley, Sanislow,
et al., 2006; Stoeber & Otto, 2006). NSSI has been shown to have
an emotion regulating function; that is, a way of coping with negative emotions (Claes et al., 2010; Klonsky, 2007). The interpersonal-inuence model conceptualises NSSI as a cry for help, a
means of avoiding abandonment, or an attempt to affect peoples
behaviour (Klonsky, 2007). Given that individuals high on ECP
are particularly vulnerable to negative affect, they might be prone
to engage in NSSI as a way to regulate their emotions and as a way
to signal their distress to other people in particular.
Secondly, as ECP involves harsh self-criticism and a self-derogatory
orientation, it may, in the long run, result in pervasive feelings of
worthlessness and even self-hate (Blatt, 1995). Such feelings may, in
turn, increase the likelihood of engaging in self-destructive and selfpunitive behaviours such as NSSI (Claes et al., 2010; Klonsky,
2007). Consistent with this reasoning, research has shown that NSSI
may serve functions of self-punishment and self-torture. In this
view, NSSI is considered an expression of anger or derogation towards
oneself learned by an invalidating environment (Klonsky, 2007).
To gain more insight in the dynamic processes involved
in the perfectionism-NSSI association, we examined whether perfectionism would relate to three functions of NSSI namely a cry

L. Claes et al.

for help, self-punishment and self-torture. Previous research on

these associations is scarce and no study relied on a sample of ED
patients. Nock and Prinstein (2005) found a positive association
between ECP and social reinforcement functions of NSSI in
adolescent psychiatric inpatients, suggesting that adolescents were
attempting to use NSSI to solicit assistance from others (i.e., social
positive reinforcement) or to remove the perceived expectations of
others (i.e., social negative reinforcement). Furthermore, Glassman
et al., (2007) found that self-criticism was related positively to selfpunishment as a motive for NSSI but not with other functions of
self-injury.
Parental criticism, perfectionism and nonsuicidal
self-injury
The third aim of this study was to address the role of perceived
parental criticism (PPC) in relation to ECP and NSSI. Different
scholars have argued that an orientation of parental criticism,
where parents set high standards for their children and excessively
criticise their children when they fail to meet these standards,
contributes to the development of NSSI (Glassman et al., 2007;
Yates, Tracy & Luthar, 2008). Consistent with this notion, associations have been shown between NSSI and different expressions
of harsh and inadequate parenting such as parental criticism
(Yates et al., 2008; Hoff & Muehlenkamp, 2009), parental
expressed emotion (Wedig & Nock, 2007) and child maltreatment
(Glassman et al., 2007).
Parental criticism may be a risk factor for NSSI for it may contribute to a self-critical intrapersonal orientation. Individuals who
were excessively criticised and verbally/emotionally abused by
their parents mayover timelearn to engage in excessive selfcriticism themselves and use NSSI as a form of self-punishment
(Glassman et al., 2007; Yates et al., 2008). Such formulations are
consistent with the literature on the developmental origins of perfectionism (Blatt, 1995; Flett, Hewitt, Oliver & Macdonald, 2002),
in which harsh, critical and controlling parenting is considered a
key antecedent of perfectionism.
Indeed, research has shown consistent evidence for an association between harsh/critical parenting and self-criticism or ECP in
particular (Frost et al., 1993; McCranie & Bass, 1984). Further, a
number of studies have shown that ECP plays a mediating role
in associations between harsh/critical parenting and psychopathology in children and adolescents (Kenney-Benson & Pomerantz, 2005). Similar evidence for this sequence of mediation in
the domain of NSSI, however, is inconsistent. Glassman et al.
(2007), for instance, found that adolescent self-criticism mediated
associations between parental emotional abuse and NSSI but not between parental criticism and NSSI. Wedig and Nock (2007) did not
nd support for a mediating role of adolescent self-criticism in
relations between expressed emotion and self-injurious behaviour.
Given the inconsistent evidence for the hypothesis that ECP
mediates between perceived critical parenting and NSSI, it was
deemed important to revisit this hypothesis in the current study
with ED patients.
The present study
The rst aim of this study was to examine mean-level differences
between ED patients with and without NSSI in terms of PSP and
ECP. We hypothesised that ECP would be more strongly and
Eur. Eat. Disorders Rev. (2011) 2011 John Wiley & Sons, Ltd and Eating Disorders Association.

L. Claes et al.

perhaps even uniquely related to NSSI. To provide an additionally

conservative test of this hypothesised association, we decided to
control for severity of ED symptoms when comparing the two
groups. The second aim was to examine associations between
functions of NSSI and perfectionism. Thirdly, we aimed to examine whether PPC would be related to NSSI and whether ECP
would play a mediating role in this association.

Method
Participants
The ED sample consisted of 95 women admitted to a specialised
inpatient treatment unit. Patients were diagnosed according to
Diagnostic and Statistical Manual of Mental Disorders-IV
criteria (American Psychiatric Association, 1994) on the basis
of a standardised interview and questionnaire (Eating Disorder
Evaluation Scale; Vandereycken, 1993): 44 patients were diagnosed as anorexia nervosa, restrictive type, 12 as anorexia
nervosa, bingeing-purging type, 28 as bulimia nervosa and 11
as eating disorder not otherwise specied. The age of the ED
sample ranged from 14 to 42 years, with a mean of 21.5 years
(SD = 6.23). No signicant age differences were found between
the different ED groups [F(3, 91) = 0.63, ns]. On the Self-Injury
Questionnaire (see further on), 37 patients (38.9%) reported
at least one type of NSSI, whereas 58 (61.1 %) patients did
not display any type of NSSI. The presence/absence of NSSI
was not signicantly related to the different ED subtypes
(w2(3) = 5.07, ns). Of the 37 NSSI patients, 20 (21.1%) displayed
cutting, 19 (20.0%) hair pulling, 14 scratching (14.7%), 12
bruising (12.6%) and four (4.2%) burning.
Procedure
Eating disorder patients completed questionnaires as a part of the
routine assessment at admission. Participation was voluntary and
anonymity was guaranteed. All participants gave written informed
consent. The study was approved by the university Institutional
Review Board and by the Ethical Committee of the hospital
concerned. All items were rated on Likert scales ranging between
1 (completely disagree) and 5 (completely agree), unless indicated
otherwise.
Measures
Nonsuicidal self-injury. Using the Self-Injury Questionnaire (Claes
et al., 2003), patients were asked if they have deliberately injured
themselves (yes/no) in the past year by means of hair pulling,
scratching, bruising, cutting and/or burning. If so, they were to
specify how often this happened and which functions were served
by their NSSI (I feel the need to punish myself; I can physically
torture myself, to punish myself; I injure myself to show others
that something is wrong). Next, they were asked if they felt some
pain, and what kind of emotional experiences they had at the moment of self-injury. Additionally, patients were asked to provide
information about the age of onset of NSSI and the body parts
that were injured.
Intrapersonal perfectionism. The participants completed the
Dutch version (Soenens, Luyckx et al., 2008; Soenens, Vansteenkiste
et al., 2008) of the Multidimensional Perfectionism Scale (MPS;
Frost et al., 1990). In this article, we report on the ndings obtained
Eur. Eat. Disorders Rev. (2011) 2011 John Wiley & Sons, Ltd and Eating Disorders Association.

The Scars of the Inner Critic

with the three subscales of the MPS reecting intrapersonal perfectionism: CM (nine items, I should be upset if I make a mistake),
doubts about actions (DA, four items, I usually have doubts about
the simple everyday things I do), and PS (seven items, I set higher
goals for myself than most people). Previous factor-analytical studies have shown that items from the CM and the DA subscales load
together on a single factor that has been labelled maladaptive perfectionism or, as we prefer, ECP, whereas the items of the PS load
together on a separate factor labelled adaptive perfectionism or
PSP (Dunkley, Blankstein et al., 2006; Dunkley, Sanislowet al.,
2006). To examine the distinction between ECP and PSP in our
sample, we performed a Principal Components Analysis of the 20
items for intrapersonal perfectionism. Two components had an
eigenvalue larger than 2 and the scree-plot also pointed to a twocomponent solution, explaining 48.93 % of the variance. The rst
component was mainly dened by items from the CM and DA subscales. The second component was dened by items from the PS
subscale. Given these ndings, we computed an average score of
the items for CM and DA, and we used this score as a measure of
ECP (Cronbachs a = .84). The score for PS was used as a measure
of PSP (Cronbachs a = .88; for this procedure, see Dunkley,
Blankstein, et al., 2006; Dunkley, Sanislow et al., 2006; Soenens,
Luyckx, et al., 2008; Soenens, Vansteenkiste, et al., 2008).
Perceived parental criticism. To assess PPC, we used another
subscale from the MPS, the Parental Criticism Scale (four items,
As a child, I was punished for doing things less than perfectly).
This scale has been used as a measure of parental criticism in previous research on parenting, perfectionism and NSSI (Yates et al.,
2008). Cronbachs a in this study was .72.
Severity of eating disorder symptoms. Because we aimed to
control for severity of ED symptoms when predicting NSSI, the
participants completed the three main scales from the Dutch
version (Van Strien, 2002) of the Eating Disorder Inventory-II
(EDI-II) (Garner, 1991), that is, drive for thinness (Cronbachs
a = .87), bulimia (Cronbachs a = .94), and body dissatisfaction
(Cronbachs a = .95). The participants rated how much each item
applied to them on a scale ranging from 1 (never) to 6 (always).
Information on the validity and psychometric characteristics of
the EDI-II is provided in Garner (1991).
Statistical analyses
The examine the mean level differences in ECP, PSP and PPC
between ED patients with and without NSSI, we performed a
multivariate ANCOVA with the presence/absence of NSSI as independent variable, ED severity as covariate and the perfectionism
scales as dependent variables. To investigate the associations between the perfectionism scales and the possible functions of NSSI,
we performed linear regression analyses with the functions of
NSSI as dependent variables and the perfectionism scales as independent variables or predictors.
And nally, to examine the mediating role of intrapersonal perfectionism between PPC and NSSI, we followed the procedure of Kenny,
Kashy and Bolger (1998). Step 1 involves determining the magnitude
of the association between the independent (i.e., PPC) and dependent
variable (i.e., presence/absence of NSSI). Step 2 requires nding a signicant association between the independent (i.e., PPC) and mediating variable (i.e., intrapersonal perfectionism). Step 3 requires nding
a signicant association between the mediating and dependent

L. Claes et al.

The Scars of the Inner Critic

variable, thereby controlling for the independent variable. Finally, in

Step 4, the decrease in the association between the independent and
dependent variable after controlling for the mediating variable is
inspected. Mediation is shown (i) when an initially signicant
association in Step 1 is reduced to nonsignicance in Step 4, and
(ii) when both indirect associations in Step 2 (independent variable
to mediating variable) and Step 3 (mediating variable to dependent
variable) are signicant. We also performed the Sobel test, a
commonly used test for statistical signicance of the indirect effect
(=mediation effect).

Results
Mean-level differences between patients with and
without nonsuicidal self-injury
Table 1 presents the means and standard deviations of ED patients
with and without NSSI on ECP, PSP and PPC controlled for ED
severity. A multivariate ANCOVA-analysis indicated that, across
all outcomes, both groups signicantly differed from each other
(Wilkss Lambda = 0.88, F(3, 83) = 3.65, p < .01). Subsequent univariate ANOVA-analyses indicated that after controlling for ED
severity, ED patients with NSSI scored signicantly higher on
ECP and PPC compared with ED patients without NSSI. However, both ED groups did not differ on PSP.
Associations between perfectionism and functions
of nonsuicidal self-injury
To investigate the association between the perfectionism scales and
possible functions of NSSI, we performed linear regression analyses
with the functions of NSSI (self-punishment, self-torturing, cry for
help) as dependent variables and ECP, PSP and PPC as independent
variables (Table 2). The results showed signicantly positive
associations between self-punishment/self-torturing and ECP. The
cry-for-help function showed a signicantly positive relation with
ECP and a negative relation with PPC.
Perfectionism as mediator between parental
criticism and nonsuicidal self-injury
To investigate the mediating role of intrapersonal perfectionism
between PPC and NSSI (see Figure 1), we followed the procedure
of Kenny et al. (1998). Because we did not nd an initial association between PSP and NSSI and because PPC was unrelated to
Table 1 Means and standard deviations of evaluative concerns perfectionism,
personal standard perfectionism and parental criticism for eating disorder patients
with and without nonsuicidal self-injury controlled for eating disorder severity

Evaluative concerns
Personal standards
Parental criticism

No NSSI

NSSI

(N = 55)

(N = 35)

SD

SD

F-value

3.55
3.78
2.10

0.75
0.78
0.78

3.92
3.76
2.60

0.68
0.86
1.09

5.58*
0.11
5.62*

NSSI, nonsuicidal self-injury.

*p < 0.05, **p < 0.01, ***p < 0.001

Table 2 Regressions with the different functions of nonsuicidal self-injury as

dependent variables and evaluative concerns perfectionism, personal standard
perfectionism and parental criticism as independent variables

Evaluative concerns
Personal standards
Parental criticism

Function 1

Function 2

Function 3

Self-punishment

Self-torturing

Cry-for-help

0.30*
0.04
0.13

0.30*
0.12
0.03

0.36**
0.01
0.29**

*p < 0.05
**p < 0.01, ***p < 0.001

PSP (b = 0.04, p > .05), we could not perform the mediation

analyses with PS. Mediation analyses were performed for ECP
only. In line with the previous studies (Kenney-Benson &
Pomerantz, 2005; Soenens, Luyckx, et al., 2008), scores for ECP
were adjusted for PSP. This procedure is thought to result in a
more pure assessment of the core features of ECP (Stoeber &
Otto, 2006). Specically, ECP was regressed on PSP and the residualized score was used as a measure of ECP.
A regression analysis showed that the effect of PPC on NSSI
(Step 1) was signicant (b = .28, p < .01). The effect of PCC on
ECP (Step 2) was also signicant (b = .34, p < .001). When entering PPC and ECP simultaneously in the prediction of presence/
absence of NSSI, ECP was signicantly and positively associated
with the presence of NSSI (Step 3; b = 0.22, p < 0.05). Finally,
PPC was no longer a signicant predictor of the presence/absence
of NSSI (Step 4; b = .21, ns). These ndings suggest that the initially signicant association between PPC and NSSI is reduced
to nonsignicance after taking into account ECP and as such,
provide support for the mediating role of ECP. The Sobel test statistic z = 1.91, p = 0.05 points in the same direction, although the
p-value is only borderline signicant.

Discussion
Although it is conceptually plausible to consider perfectionism as
a risk factor for NSSI, relatively few studies have empirically
addressed associations between perfectionism and NSSI. Moreover, most studies to date have relied on community samples.
The main aim of this study was to examine this association in a
sample where both perfectionism and NSSI are known to be elevated and salient. Indeed, we found that 38.9% of the ED inpatients in this study showed at least one type of NSSI, which is in line
with ndings of Svirko and Hawton (2007) who reported prevalence rates ranging from 25.4% to 55.2% in ED patients.
In examining associations between perfectionism and NSSI in
ED patients, we adopted, in line with the heavily growing body
of work on perfectionism outside the clinical domain, a twodimensional approach to perfectionism (Stoeber & Otto, 2006),
distinguishing between PSP (i.e., the setting of high standards
and goals for oneself) and ECP (i.e., the tendency to be concerned
about making mistakes and to engage in self-criticism). We found
that only ECP (but not PSP) was elevated among ED patients with
NSSI, even after controlling for severity of ED symptoms. This
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L. Claes et al.

The Scars of the Inner Critic

= 0.28** ( =0.21, ns)a

Perceived Parental

NSSI (0/1)

Criticism (PPC)

= 0.34***

Evaluative Concerns
Perfectionism (ECP)

=0.29**
( =0.22*)

Figure 1. The mediating role of intrapersonal perfectionism between perceived parental criticism and nonsuicidal self-injury. Beta coefcients without brackets refer
to the correlation coefcients between the variables that are linked by an arrow. Beta coefcients between brackets () refer to the regression weights of the regression analysis in which perceived parental criticism and evaluative concerns perfectionism were simultaneously included as predictors of nonsuicidal self-injury

nding is consistent with the previous research in community

samples. Hoff and Muehlenkamp (2009), for instance, found elevated levels of concern about mistakes (one key aspect of ECP) in
college students with NSSI.
The unique association between ECP and NSSI is an interesting
nding in the light of the ongoing debate about the adaptive value
of both dimensions of perfectionism. Some scholars have argued
that only ECP represents a risk factor for psychopathology and
that PSP may even represent a protective or adaptive personality
dimension (Stoeber & Otto, 2006). Others have argued that PSP
does represent a vulnerability factor to psychopathology, although
its association with psychopathology may be more conditional
upon other risk factors (negative life events) or indirect compared
with associations between ECP and psychopathology. At rst
sight, our ndings seem to be in line with a view on ECP as being
maladaptive and with PSP as being harmless or even adaptive.
Further, as in many other studies, we obtained a strong and
positive association between the two dimensions of perfectionism,
indicating that people high on PSP are likely to also engage in selfcritical and self-evaluative perfectionist thinking. Thus, across
time, PSP may elicit ECP and be indirectly related to NSSI
through increases in ECP. Finally, it seems premature to consider
PSP as a protective or adaptive factor in the context of NSSI because it was unrelated rather than being negatively related to
NSSI. This leaves open the possibility that, under particular circumstances, PSP does predict NSSI. On the basis of diathesisstress models, it has indeed been argued that PSP may interact
with stress and negative life events to predict psychopathology
(Hewitt et al., 1996) and some evidence for this argument in the
context of NSSI was obtained by OConnor et al. (2010).
Having documented an association between ECP and NSSI, the
second aim of this study was to examine associations of this
perfectionism dimension with functions underlying NSSI. We
reasoned that ECP might be related to NSSI for at least two reasons: (i) because NSSI is an expression of self-hate, and (ii)
because NSSI can be considered an emotion regulation mechanism. Both proposed mechanisms received some support in this
study. First, we found that ECP was related positively with the
self-punishing and self-torturing functions of NSSI. Because of
their self-critical orientation, people scoring high on ECP may,
in the long run, develop deep-seated feelings of inferiority and
possibly even self-hate. Such pervasive negative self-evaluations
Eur. Eat. Disorders Rev. (2011) 2011 John Wiley & Sons, Ltd and Eating Disorders Association.

may trigger the use of NSSI as a means of self-punishment and

self-torture. This nding is consistent with Glassman et al. (2007),
who found a positive association between self-criticism and the
self-punishment function of NSSI. According to Glassman et al.
(2007), individuals high on self-criticism, who often have a
history of being criticised, learn to engage in NSSI as a form of
self-punishment or self-abuse. In line with this reasoning, we also
found that PPC, much like ECP, was related positively to the selfpunishing function of NSSI.
Second, we found that ECP was related to the cry-for-help
function of NSSI. Because ECP is known to render individuals
vulnerable to negative emotions (Dunkley, Blankstein, et al.,
2006; Dunkley, Sanislow, et al., 2006) and because it may also undermine individuals capacity to deal with negative emotions in an
open and constructive fashion, ECP may relate to derivative and
compensatory ways of regulating negative emotion. Using NSSI
as a means to solicit other peoples attention may represent one
such mode of emotion regulation.
In contrast to these ndings and unexpectedly, we found that
PPC was related negatively to this cry-for-help function of NSSI.
Possibly, parental criticism may not only elicit a self-critical orientation but may also contribute to an avoidant interpersonal orientation. Individuals with a history of parental criticism may have
learned to anticipate that socialisation gures will respond aversively when solicited for emotional support. As a consequence,
they may avoid other people when they are in distress and avoid
signalling their distress through cries for help. In a similar vein,
parental criticism may contribute to an orientation of toughmindedness, where people become hard, ruthless and unfeeling
(Duckitt, 2001). With such an orientation, a cry for help may be
considered as a sign of weakness that should be avoided. It should
be noted that this unexpected negative association between parental criticism and the cry-for-help function of NSSI is inconsistent
with the study of Nock and Prinstein (2005), who found a positive
correlation between socially prescribed perfectionism and social
functions of NSSI in adolescent psychiatric inpatients. Thus, future research is needed to replicate this association and to examine its meaning. Future research is also needed (i) to examine
associations between perfectionism and other functions of NSSI
that relate to this mechanism of emotion regulation (using NSSI
to avoid feeling numb and using NSSI to feel unique and invulnerable), and (ii) to examine additional plausible mechanisms

L. Claes et al.

The Scars of the Inner Critic

behind the perfectionism-NSSI link. For instance, perfectionist

people and people scoring high on ECP in particular, are known
to have a strong urge for control and predictability (Shafran &
Mansell, 2001). Their rigid and relentless striving for excellence
might, in itself, be considered as an attempt to control and master
ones environment. Because NSSI behaviours have also been
identied as attempts to gain control (Klonksy & Muehlenkamp,
2007), it seems likely that perfectionists may engage in NSSI to
bring some kind of structure, control and predictability in their
lives.
The third aim of this study was to examine whether ECP would
represent a mediating variable between PPC and NSSI. Developmental theory indeed suggests that parental criticism creates a
vulnerability to psychopathology through the development of a
perfectionist orientation (Flett et al., 2002). ECP was found to mediate the link between PPC and NSSI in ED patients. We should
keep in mind, however, that it concerns the patients perception
of parenting and that any direction of causality cannot be inferred
from the current cross-sectional study (see following paragraph
on limitations). Nevertheless, our ndings are in line with the idea
that parental criticism carries over into NSSI in ED patients
through ECP. Past research had identied associations between
critical parenting and ECP (McCranie & Bass, 1984) and between
critical parenting and psychopathology in children and adolescents (Kenney-Benson & Pomerantz, 2005). Our study was
among the rst to demonstrate the mediating role of ECP between parental criticism and NSSI. Although Glassman et al.
(2007) did not obtain convincing evidence that adolescent selfcriticism mediated the association between parental criticism
and NSSI in a community sample of adolescents, we did obtain
such evidence in a sample of ED patients, possibly because the developmental process involving parental criticism, self-criticism
and NSSI is more salient in such a sample.
Limitations
Although we consider the reliance on a sample of ED patients as a
strength of our research, this study also has a number of shortcomings that need to be addressed in future research. Like most other
studies on parenting, perfectionism and NSSI, we relied on selfreport assessment which may have caused problems with shared
method variance, such that associations between variables are
overestimated. To deal with this problem, future research may
adopt a multi-informant assessment approach where, for instance,
parenting is measured with parent reports or observational methods, or where NSSI behaviour is rated by professional observers
(nurses, therapists). Indeed, we do not want to fall in the trap of

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This study shows that ED patients with ECP are more likely to
hurt themselves, thereby leaving scares as physical signals of
self-injury on their bodies. Presumably, the inner critic that is
the characteristic of those patients leads them to engage in NSSI
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