Many individuals with eating disorders experience significant anxiety when in social situations.
According to the Free Dictionary (Farlex www.medical-dictionary.the (link is external) free dictionary.com,) “anxiety is a multisystem response to a perceived threat or danger. It reflects a combination of biochemical changes in the body, the patient’s personal history and memory, and the social situation. Although anxiety is related to fear, it is not the same thing. Fear is a direct, focused response to a specific event or object, and the person is consciously aware of it. (i.e. witnessing an approaching tornado.) Objects or events that are unique and specific to an individual often trigger anxiety. Anxiety can have a number of different causes. It is a multidimensional response to stimuli in the person’s environment, or a response to an internal stimulus (for example, a hypochondriac’s reaction to a stomach rumbling) resulting from a combination of general biological and individual psychological processes.”
The current DSMIV (Diagnostic & Statistical Manual of the American Psychiatric Association (1994) criteria for Social Anxiety are:
A. A persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be embarrassing and humiliating.
B. Exposure to the feared situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally pre-disposed Panic Attack.
C. The person recognizes that this fear is unreasonable or excessive.
D. The feared situations are avoided or else are endured with intense anxiety and distress.
E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
F. In individuals under age 18 years, the duration is at least 6 months.
G. The fear or avoidance is not due to direct physiological effects of a substance (e.g., drugs, medications) or a general medical condition not better accounted for by another mental disorder.
A 2004 study reported in the American Journal of Psychiatry examined the relationship between anxiety and eating disorders in 672 people with anorexia, bulimia, or both disorders. The study participants were evaluated in terms of anxiety, perfectionism, and obsessive behavior using a diagnostic interview based on the DSM-IV (link is external) criteria. The results of the study showed that approximately two-thirds of those who had an eating disorder also suffered from an anxiety disorder. The Academy for Eating Disorders (AED) has embraced that certain individuals who have pre-existing anxiety and/or depression are more likely to develop eating disorders.
Individuals with eating disorders often report that their anxiety generally centers on fear of criticism or humiliation when in public or social situations. Typically, they fear being judged in both body shape and size and for how and what they eat (i.e. eating rituals like cutting up food in to little pieces or avoiding foods with certain ingredients, particularly fat.) Often, the self-loathing, shame and self-criticism that eating disorder sufferers typically feel with respect to their own body, is projected on to other people who they imbue with the power to hurt them or make them not feel safe or valued. If the assumption is that someone else is thinking negative thoughts or will make critical statements, then the environment is not safe, whether this is based on perception or reality. Eating disorder sufferers are extremely vulnerable to negative thought, whether it is their own, others or even how they perceive others to feel about them. Patients also report feeling the need to accommodate other peoples feelings at the expense of their own, not feeling that they fit in, not being able to assert their point of view, essentially not feeling comfortable in their own skin when in the company of other people. Some patients report that these feelings and interpersonal issues are significantly reduced or disappear in the safe world and solitude with food. Social situations often stimulate and resurrect the internal negative voice; avoiding people and the situation altogether keeps the voice silenced or quieter. It feels safer to be alone.
Most of us in the eating disorder professional community accept that anxiety often is accompanied with an eating disorder and the eating disorder acts to ameliorate the anxiety i.e. not eating or restricting food acts to reduce anxiety – if I don’t eat or eat only certain foods I can feel in control of anxiety, and the purging effects of bulimia have shown to both physiologically and psychologically have a calming effect.)
Perhaps we can shed more light on social anxiety if we start to examine why some patients with eating disorders tend to feel safest when they are alone rather than only focusing on why they feel anxious in social situations. (Perhaps, this is just the other side of the same coin.) There are several questions to consider. “Does being alone maintain a state of calm? Is the anxiety free floating and present whether the individual is alone or not? Is anxiety reduced or soothed by avoiding social situations? Do cravings for food and negative self-talk increase or decrease when in social situations versus being alone? In this way, understanding what is driving the anxiety can be particularly helpful in targeting how to diagnosis and treat the person experiencing it. Perhaps there are more psychological and/or interpersonal anxiety factors to then consider – i.e. it is their own negative self-view, fear of criticism, lack of trust in other people and inability to trust themselves and their worth to others that induces an anxious state? Do these interpersonal and psychological issues therefore reinforce the belief that they are better off alone?
Being alone offers solace from judgment and criticism (whether perceived or actual.) The relationship with food is compelling, stimulating, comforting and accepting; after all, food does not judge the way people can. To assume that the environment one enters into socially is safe is often too much for some people with eating disorders to believe or expect; being alone provides safety. Exploring how anxiety can be focused around interpersonal and relational issues in addition to a general state of free floating (likely, biologically driven) anxiety can be extremely useful in understanding a person and in establishing treatment goals and assessing outcomes. It can be important for health and mental health care practitioners to help patients distinguish from where their anxiety originates and then how to treat it – what is driving the anxiety bus – free floating, indiscriminate anxiety or specifically targeted to interpersonal or psychological forces.