Background
While eating disorders have a high comorbidity with anxiety disorders, little is presently known about how anxiety links to eating attitudes and behaviours and other related characteristics of eating-disordered individuals. The present study aimed to determine whether social anxiety and agoraphobia in eating-disordered individuals are linked to different eating attitudes and behaviours and levels of ego functioning.
Method
The participants were 70 women who met DSM-IV criteria for an eating disorder. The Eating Disorder Inventory (EDI) was used as a measure of eating attitudes and ego-functioning characteristics, while the Social Phobia and Anxiety Inventory (SPAI) was used as a measure of levels of social anxiety and agoraphobia.
Results
High scores on the eating attitude scales of the EDI were associated with higher levels of social anxiety in eating-disordered individuals. High scores on the ego-dysfunction scales of the EDI were associated with higher levels of social anxiety and agoraphobia. Conclusions. The present findings suggest that eating-related attitudes and behaviours are associated with high levels of social anxiety, while psychological characteristics not specifically related to eating are associated with anxiety more broadly. The results highlight the importance of identifying and addressing comorbid anxiety in eating-disordered individuals, and suggestions are made for the treatment of such cases. Implications for future research are also discussed.
Clinical studies have consistently noted elevated rates of anxiety in women with anorexia and bulimia nervosa (Bulik, 2003). Theoretical accounts of the aetiology and maintenance of eating disorders have argued that anxiety and anxiety reduction are central to the understanding and treatment of eating pathology. For example, the anxiety reduction model (Rosen & Leitenberg, 1985) proposes that vomiting in bulimics serves as an “escape” response, reducing their anxiety about body shape and weight, triggered by eating “forbidden foods”. While the comorbidity with certain types of anxiety (i.e., obsessive–compusive disorder) is well established in the literature, other manifestations of fear, such as social anxiety and agoraphobia/panic, have received less research attention (O'Brien & Vincent, 2003).
Social anxiety is a fear of negative evaluation by others—a concern that other people see the individual as inferior in some way (Beck, Emery, & Greenberg, 1985). It can be provoked by a wide range of situations, including public speaking, meeting new people, and eating or writing in front of others. In contrast, agoraphobia refers to the avoidance of situations that are likely to trigger panic attacks. These are defined as sudden-onset intense feelings of fear or apprehension, which are associated with physical symptoms such as palpitations, breathlessness, dizziness, and trembling. While occasional panic attacks are common in all anxiety disorders (Barlow et al., 1985), the diagnosis of panic disorder with agoraphobia applies only to individuals who experience recurrent panic attacks, at least some of which come on “out of the blue”.
Preliminary findings show that social anxiety and agoraphobia are common in patients with eating disorders. For example, Hinrichsen, Wright, Waller, and Meyer (2003) showed that levels of social anxiety in patients with anorexia and bulimia nervosa are significantly elevated compared to control women, and that social anxiety is associated with higher levels of eating psychopathology in bulimic individuals. Schwalberg, Barlow, Alger, and Howard (1992) found that 10% of bulimics and 13.6% of obese binge eaters fulfil criteria for a lifetime diagnosis of agoraphobia. These initial findings lend support to the hypothesis that both social anxiety and agoraphobia might be functionally linked to eating psychopathology and to related psychological characteristics.
The aim of this study was to determine the relative predictive power of social anxiety and agoraphobia in explaining eating attitudes/behaviours and associated attitudes among eating-disordered women. As there is considerable symptom overlap between these two anxiety disorders, the present study used a measure that allows for the assessment of social anxiety and agoraphobia as distinct concepts.
