While social anxiety and agoraphobia are commonly observed in patients with eating disorders, little is known about the types of family environment that may predispose patients to the development of these types of comorbid anxiety problem. The present study investigated whether social anxiety and agoraphobia in patients with eating disorders are linked to different types of parenting experiences. A sample of 70 women meeting DSM-IV criteria for an eating disorder completed self-report measures of social anxiety, agoraphobia and perceived parenting experiences. Social anxiety in patients with eating disorders is associated with emotionally inhibited parenting by fathers (i.e., parenting that reflects a lack of ability to share feelings with the child), while agoraphobia is associated with anxious/fearful parenting by mothers (i.e., parenting that reflects anxious, fearful traits in the parent and a pessimistic outlook on life). Specific parenting experiences may contribute to the development of comorbid social anxiety and agoraphobia in patients with eating disorders. Implications for future research and clinical practice are discussed.
Anxiety disorders are common among patients with eating disorders, and frequently predate the emergence of the eating disorder (Bulik, 2003). This finding has led clinicians and researchers to suggest that anxiety plays a significant role in the aetiology and maintenance of these problems (e.g., Arnow et al., 1992 and Arnow et al., 1995). For example, Rosen and Leitenberg (1985) have proposed that in bulimic disorders vomiting serves to reduce patients' anxiety about changes in their shape and weight following a binge. Two of the most commonly observed comorbid anxiety problems in the eating disorders are social anxiety and agoraphobia (e.g., Schwalberg, Barlow, Alger, & Howard, 1992). Social anxiety is a fear of social situations in which an individual may be exposed to unfamiliar people or the scrutiny of others. In these situations, the person fears that they will act in a way (or show signs of anxiety) that will lead to humiliation or embarrassment. In contrast, agoraphobia is anxiety about being in places or situations from which escape might be difficult. Sufferers fear that they will not be able to obtain help in the event of a panic attack or panic symptoms (DSM-IV-TR; American Psychiatric Association, 2000).
Addressing such comorbid anxiety states depends on being able to identify and modify the cognitions that drive them. Hinrichsen, Waller and Emanuelli (2004) have shown that social anxiety and agoraphobia in the eating disorders are linked to different core beliefs (unconditional negative beliefs about the self, other people or the world). They found that high levels of social anxiety are associated with abandonment beliefs (the belief that significant others will not continue providing emotional support) and with emotional inhibition beliefs (the belief that one should inhibit the expression of spontaneous feelings to avoid disapproval by others). In contrast, agoraphobia is associated with vulnerability to harm beliefs (the belief that a catastrophe is about to strike and that one will not be able to prevent it). Unlike more superficial cognitions, modification of core beliefs requires an understanding of their origins (Young, Klosko, & Weishaar, 2003). Speculating on the origins of negative core beliefs, Young (1999a) has proposed that they develop in childhood, partly as a result of a person's parenting experiences. While they may have an adaptive function in a child's early environment (e.g., a vulnerability to harm core belief might help to protect a child from physical abuse), they can become maladaptive in adulthood once the person's circumstances change (e.g., they are in a loving and supportive relationship) if the person continues to act in accordance with the core belief.
Sheffield, Waller, Emanuelli, Murray and Meyer (2005) tested Young's (1999a) hypotheses regarding the links between patients' perceived parenting experiences and the presence of core beliefs. They used the Young Parenting Inventory (YPI; Young, 1999b) — a clinical measure designed specifically for this purpose. While they did not find all of Young's hypothesized links to be supported, a shorter version of the YPI (the YPI-R) showed meaningful associations between parenting experiences and core beliefs. Sheffield et al. (2005) identified nine types of parenting experiences that can be linked to the development of specific core beliefs. Combining the findings of that study with those of Hinrichsen et al. (2004), it can be hypothesized that punitive parenting (parenting that is punitive of the child's mistakes) contributes to the development of abandonment and emotional inhibition core beliefs, which in turn makes it more likely that the individual will develop social anxiety. In contrast, pessimistic/fearful parenting (parenting that reflects fearful traits in the parent and a pessimistic outlook on life) is likely to contribute to the development of vulnerability to harm core beliefs, making it more likely that the individual develops agoraphobia.
This study tests this hypothesized set of links between eating-disordered patients' perceived parenting experiences and their levels of comorbid social anxiety and agoraphobia. We predicted that punitive parenting would be associated with high levels of social anxiety, while pessimistic/fearful parenting would be associated with higher levels of agoraphobia in patients with eating disorders.
