Anorexia Nervosa & Social Anxiety Disorder: A Systemic Review

By Michelle L. Miller, BS and Jennifer R. Ferrante, BA, BS

Posted in Gurze Eating Disorders Review February 2, 2020

Individuals with anorexia nervosa often struggle socially, battling fears of public scrutiny and judgement regarding their weight and shape1. Up to 34% of individuals with anorexia nervosa will experience symptoms that meet clinical criteria for social anxiety disorder, and many more will experience subclinical symptoms2. Additionally, study participants are often recruited from treatment programs; this excludes those individuals whose social anxiety may have prevented them from initiating or maintaining treatment, and likely results in an underestimation of the true prevalence of social anxiety in this population. A better understanding of the relationship between social anxiety and anorexia nervosa is crucial for improving diagnosis, treatment, and overall quality of life for individuals with anorexia nervosa.

Among individuals with anorexia nervosa, symptoms of social anxiety are often associated with concerns regarding one’s appearance. For example, social appearance anxiety, or anxiety specifically related to fears of negative evaluation of one’s appearance, is positively associated with symptoms of social anxiety in individuals with anorexia nervosa3. Interestingly, this social appearance anxiety does not appear to be restricted to weight-related concerns, as patients with anorexia nervosa and non-weight-related body image concerns score higher on measures of social anxiety as compared to individuals with anorexia nervosa and exclusively weight-related body image concerns4. Social anxiety related to both weight-related and non-weight related body image concerns may represent the high prevalence of body dysmorphic disorder5 or the increased public self-consciousness6-7 among individuals with anorexia nervosa.

The social anxiety that individuals with anorexia nervosa experience is complex and cannot be solely attributed to concerns regarding one’s appearance. Symptoms of social anxiety among individuals with anorexia nervosa are also positively associated with alexithymia traits, such as difficulty identifying and describing feelings8, as well as internalized shame9. In addition, underlying traits may exist that predispose a person to develop both anorexia nervosa and social anxiety disorder. For example, individuals with anorexia nervosa are more likely to possess certain traits associated with social anxiety, such as public self-consciousness6-7, interpersonal distrust10, perfectionism11-12, doubts about being understood13, doubts about being the same13, and poor interoceptive awareness6 as compared to healthy controls. Conversely, extraversion is negatively associated with symptoms of social anxiety among individuals with anorexia nervosa and may serve as a protective factor against social anxiety in this population6.

Alternatively, social anxiety in itself may represent an underlying vulnerability promoting the development and progression of anorexia nervosa symptoms, as 74% of individuals with an eating disorder report the onset of social phobia as preceding the onset of eating disorder14. Once an individual develops symptoms of both social anxiety and anorexia nervosa, these symptoms may exacerbate each other. For instance, individuals with more severe social appearance anxiety3 and who use more social safety behaviors15 also experience more severe symptoms of anorexia nervosa. Symptoms of social anxiety may allow symptoms of anorexia to progress via preventing individuals from entering and maintaining treatment of their eating disorder. Specifically, increased social anxiety among individuals with anorexia nervosa and bulimia nervosa is associated with less likelihood of entering outpatient eating disorder treatment after an initial intake appointment16.

Even if individuals with comorbid social anxiety and anorexia nervosa enter and maintain adherence to a treatment program, they may face unique challenges during eating disorder treatment. The same traits that may create a vulnerability for the development of comorbid social anxiety and anorexia nervosa, such as interpersonal distrust10 and doubts about being understood13, may also impede the formation of the therapeutic alliances crucial for treatment maintenance and success. An inability to enter, maintain, or benefit from treatment may explain the association between more time ill with anorexia nervosa and more severe social anxiety symptomatology17. Further research is needed to better understand and elucidate the complex relationship between symptoms of anorexia nervosa and social anxiety, with the goal of identifying interventions that will make anorexia nervosa treatment more feasible and effective for individuals with comorbid social anxiety.