Fagan describes the prevalence of what she calls “destructive perfectionism” among high-achieving young people. Standardized testing and hyper-competitive college admissions place pressure on students to excel. The rise of social media has increased the social pressure on young people, who are constantly presented with other people’s more perfect-seeming lives. For many young people, their sense of self-worth has become tied to test scores and Instagram likes, rather than an internal self-confidence. Fagan describes Madison as plagued by self-doubt. Madison gains self-esteem through athletic and academic achievements. Fagan writes, “only excellence helped chip away at self-doubt. And so she excelled” (56). Extreme perfectionism can contribute to anxiety, depression, and suicidal ideation.

The National Collegiate Athletic Association identifies Division I (D-I) as the highest level of intercollegiate athletics. Division I schools have competitive teams, extensive resources, and top-notch facilities. Madison joined a Division I track team at the University of Pennsylvania, while Fagan played for a Division I basketball team at the University of Colorado. Throughout the book, Fagan emphasizes the intense pressures of playing for a Division I school to place Madison’s anxiety in context. Fagan portrays the culture surrounding Division I as one that emphasizes overcoming struggle to become a better athlete, as exemplified by a sign she remembers at the University of Colorado that read, “Pain is weakness leaving the body” (85).