Social anxiety and disordered eating

Contents lists available at ScienceDirect
Eating Behaviors
journal homepage: www.elsevier.com/locate/eatbeh
Social anxiety and disordered eating: The influence of stress reactivity and
self-esteem
Jessica Lyn Ciarma⁎,1, Jaya Miriam Mathew
Australian Catholic University, 115 Victoria Parade, Fitzroy, Vic 3065, Australia
A R T I C L E I N F O
Keywords:
Social anxiety
Eating disorder
Self-esteem
Stress
A B S T R A C T
While previous research indicates a strong link between social anxiety and disordered eating, more research is
needed in order to understand the mechanisms that underlie this relationship. Given that stress is often
implicated in disordered eating, it was hypothesised that ones reaction to stress (i.e. stress reactivity) would
mediate the relationship between social anxiety and disordered eating. Similarly, given that low self-esteem is
commonly reported in both those with social anxiety and eating disorders, it was hypothesised that self-esteem
would also mediate the relationship between social anxiety and disordered eating. In order to test this, an online
survey measuring social anxiety, disordered eating, stress reactivity and self-esteem, was administered to 282
participants in the community, aged between 18 and 35 years. Results showed that self-esteem and a reactivity
to stress during social conflict – but not during negative social evaluations – partially mediated the relationship
between social anxiety and disordered eating. These findings demonstrate that low self-esteem and interpersonal
conflict are powerful mechanisms that can maintain eating disorder psychopathology in those who are socially
anxious. This highlights the importance of ensuring that these mechanisms are sufficiently addressed in eating
disorder prevention and treatment programs.
1. Introduction
The relationship between social anxiety and disordered eating is
well-documented. Several studies have reported positive correlations
between symptoms of social anxiety and disordered eating in clinical
and community samples (Grabhorn, Stenner, Stangier, & Kaufhold,
2006; Hinrichsen, Wright, Waller, & Meyer, 2003;
Levinson & Rodebaugh, 2012; McLean, Miller, & Hope, 2007; Menatti,
DeBoer, Weeks, & Heimberg, 2015; Wonderlich-Tierney & Vander Wal,
2010). Studies on clinical samples have reported high rates of comorbidity
between social anxiety disorder (SAD) and eating disorders. For
instance, Kaye, Bulik, Thornton, Barbarich, and Masters (2004),
reported that out of 672 individuals with an eating disorder, approximately
20% met criteria for SAD. This appears to be much higher than
in community samples, where the lifetime and 12-month prevalence of
SAD were estimated to be approximately 12.1% and 7.1%, respectively
(Ruscio et al., 2008). Further, SAD is the most common anxiety disorder
experienced in individuals with eating disorders, and studies have
reported the lifetime prevalence of SAD to be around 39% and 17%
among individuals with Anorexia Nervosa (Halmi et al., 1991) and
Bulimia Nervosa (Brewerton et al., 1995), respectively. According to
retrospective research, SAD is purported to precede the onset of eating
disorders, prompting some researchers to argue that SAD is an
important risk factor for eating disorder onset (Bulik, Sullivan,
Fear, & Joyce, 1997). The significance of SAD in individuals with eating
disorders is further underscored by the fact that symptoms of social
anxiety has been shown to predict client disengagement during eating
disorder treatment (Goodwin & Fitzgibbon, 2002).
Some theoretical perspectives, such as Interpersonal theory and
Emotion Regulation theory, offer explanation to the link between social
anxiety and disordered eating. According to Interpersonal theory,
relationship difficulties may result in emotional distress, and therefore,
binge eating may be used as a coping mechanism to alleviate such
distress (Ansell, Grilo, & White, 2012). Similarly, Emotion Regulation
theory suggests that disordered eating represents a maladaptive behavioural
response, employed to reduce heightened emotions (Hilt,
Hanson, & Pollak, 2011; Polivy & Herman, 1993). While restrictive
eating may reduce negative affect by allowing a sense of control to
be gained (Hatch et al., 2010; Lask, 2000), binge eating may be used as
a means to temporarily numb negative emotions (Hilt et al., 2011).
Therefore, consistent with the Transdiagnostic theory of eating disorders,
it is believed that regardless of the specific symptoms present,
http://dx.doi.org/10.1016/j.eatbeh.2017.03.011
Received 17 October 2016; Received in revised form 15 March 2017; Accepted 21 March 2017
⁎ Corresponding author.
1 Permanent address: 1 Derby St., Kew, Vic 3101, Australia.
E-mail addresses: jessica[email protected] (J.L. Ciarma), [email protected] (J.M. Mathew).
Eating Behaviors 26 (2017) 177–181
Available online 08 April 2017
1471-0153/ © 2017 Elsevier Ltd. All rights reserved.
MARK
all eating disorders have similar underlying psychopathology (Fairburn,
Cooper, & Shafran, 2003).
However, despite both theory and research indicating a clear link
between social anxiety and disordered eating, limited research has
tested mediation models to understand the mechanisms that may be
responsible for this relationship. Research has pointed toward the role
of fear of negative evaluations (Levinson & Rodebaugh, 2012; Menatti
et al., 2015), emotional suppression (McLean et al., 2007), shame
(Grabhorn et al., 2006), and emotional coping strategies (Hinrichsen
et al., 2003; Wonderlich-Tierney & Vander Wal, 2010) as factors that
might explain this relationship. However, Menatti et al. (2015) noted
that further research exploring mediating mechanisms is required to
fully understand the cognitive and behavioural processes implicated in
social anxiety and disordered eating.
The extent to which one interprets external situations as harmful or
unmanageable, known as stress reactivity (Scholtz, Yim, Zoccola,
Jansen, & Schulz, 2011), may potentially mediate the relationship
between social anxiety and disordered eating. Disordered eating often
emerges during, or is exacerbated by, stressful situations (e.g., transition
to university, interpersonal conflict, puberty onset), particularly in
individuals who have difficulty dealing with negative affect and stress
(Barker & Galambos, 2007; Delinsky & Wilson, 2008; Klump, Perkins,
Burt, McGue, & Iacono, 2007; Lieberman, Gauvin, Bukowski, & White,
2001). Moreover, experimental research has shown that inducing
interpersonal stress via provoking feelings of loneliness and rejection,
which are characteristic of those with social anxiety, led to an increase
in disordered eating behaviours and cognitions in individuals with
bulimia nervosa (Tuschen-Caffier & Vögele, 1999). Considering that
disordered eating may function to regulate negative emotions in
individuals with elevated levels of social anxiety, it is therefore
plausible that this relationship depends, at least in part, on individual
differences to stress reactivity (Hinrichsen et al., 2003). According to
Scholtz et al. (2011), stress reactivity in social situations can either be
in result of social evaluations (i.e. losing self-confidence in response to
negative social evaluations) and social conflict (i.e. feeling upset and
annoyed in response to social conflict or criticism). However, no studies
to our knowledge have investigated how both forms of stress reactivity
might mediate the relationship between social anxiety and disordered
eating.
Self-esteem might also be another variable underlying the relationship
between social anxiety and disordered eating. Self-esteem refers to
a person’s level of self-acceptance, which stems from an appraisal of
global self-worth, attractiveness, competence, and ability to achieve
one’s own aspirations (Robson, 1988). Self-esteem is significantly lower
in individuals with eating disorders relative to controls (Fairburn et al.,
2003), and several studies have reported negative relationships between
self-esteem and disordered eating, in both clinical and community
samples (Lampard, Byrne, McLean, & Fursland, 2011; Lampard,
Tasca, Balfour, & Bissada, 2013; Shea & Pritchard, 2007). Indeed, selfesteem
is purported to be a powerful maintaining mechanism of eating
disorder psychopathology, where it has been shown to exacerbate
shape and weight concerns and dietary restraint (Fairburn et al., 2003).
It is also well-known that self-esteem is impaired in individuals with
elevated levels of social anxiety (Clark & Wells, 1995). A persistent
negative view of the self, according to the cognitive model of SAD
(Clark & Wells, 1995), is a major reason why socially anxious individuals
interpret social situations as threatening. Consistent with this,
Obeid, Bucholz, Boerner, Henderson, and Norris (2013) found that in a
sample of 344 females with an eating disorder, social anxiety had a
negative relationship with perceived global self-worth. Therefore, it is
likely that global negative self-evaluation is a primary force maintaining
symptoms of disordered eating in individuals who are socially
anxious.
Indeed, Obeid et al. (2013) and many other researchers (e.g.
Grabhorn et al., 2006; Kaye et al., 2004) utilised clinical samples in
investigating the relationship between SAD and disordered eating.
Therefore, research utilising a non-clinical population is warranted,
given the functional impact of subclinical disordered eating on individuals
(Lewinsohn, Striegel-Moore, & Seeley, 2000). Therefore, this
study aimed to explore whether reactivity to stress in social settings
and self-esteem mediate the link between social anxiety and disordered
eating in a community sample. It is hypothesised that higher levels of
social anxiety would predict higher levels of disordered eating through
a higher reactivity to stress and low self-esteem. It is hypothesised that
reactivity to stress during both social evaluations and social conflict
would mediate the relationship between social anxiety and disordered
eating.
2. Method
2.1. Participants
Data was analysed from 282 online community participants. There
were 226 females (Mage=22.26, SD = 3.71) and 56 males
(Mage= 24.57, SD= 4.53). Ages ranged between 18 and 35 years.
This age range was selected given that research has suggested that this
period is when the onset of eating disorder psychopathology is most
common (Hudson, Hiripi, Pope, & Kessler, 2008). The majority of
participants (86%) reported that they lived in Australia.
2.2. Measures
2.2.1. Social anxiety
Social anxiety was assessed through the Liebowitz Social Anxiety
Scale (LSAS; Liebowitz, 1987).There are two subscales (social anxiety,
social avoidance), with each comprising of 24 items that are ranked on
a four-point scale, ranging from zero to three. All items are summed to
produce a total social anxiety score. Higher scores indicate higher levels
of social anxiety, with a score below 30 indicating that SAD is unlikely.
For those who met diagnosis of SAD, mean scores were found to range
between 63 and 78 (Heimberg et al., 1999). The reliability and validity
of the LSAS has been established (Heimberg et al., 1999). The LSAS
demonstrated excellent reliability for the current study (Cronbach’s
α= 0.95).
2.2.2. Disordered eating
The 26-item Eating Attitudes Test was used to assess disordered
eating (EAT-26; Garner & Garfinkel, 1979). Items are ranked on a sixpoint
scale, ranging from zero (never, rarely, sometimes) to three
(always). A total EAT-26 score is computed by summing all items and
higher scores reflect greater disordered eating severity. A score of 20 or
over is considered to be a high score, indicative of significant concerns
regarding eating and body weight and shape. The reliability and
validity of the EAT-26 has been documented (Garner, Olmsted,
Bohr, & Garfinkel, 1982) and the EAT-26 demonstrated good reliability
in the current study (Cronbach’s α =0.84).
2.2.3. Stress reactivity
The social evaluations and social conflict subscales of the Perceived
Stress Reactivity Scale (PSRS; Scholtz et al., 2011) were used in the
current study. Both subscales are comprised of five items, each ranked
on a three-point scale. Items are summed to produce a subscale score,
with higher scores indicating higher levels of perceived stress reactivity.
Mean scores in a community sample aged between 26 and 60, have
been found to range between 3 and 4 for the social evaluations
subscale, and 5–6 for the social conflict subscale (Scholtz et al.,
2011). Acceptable reliability and validity has been demonstrated
(Scholtz et al., 2011). In the current sample, the social evaluations
and social conflict subscales showed the following levels of reliability,
respectively: Cronbach’s α= 0.63 and Cronbach’s α= 0.70.
J.L. Ciarma, J.M. Mathew Eating Behaviors 26 (2017) 177–181
178
2.2.4. Self-esteem
The 10-item Rosenberg Self-Esteem (RSE) Scale was used to assess
self-esteem (Rosenberg, 1965). Each item is ranked on a four-point
scale, ranging from zero (strongly disagree) to three (strongly agree).
Items are summed to produce a total score with higher scores reflecting
higher levels of self-esteem. Scores between 15 and 25 are considered to
be within the normal range, with scores below 15 suggesting low selfesteem.
The validity and reliability of the scale has been demonstrated
(Martín-Albo, Núñez, Navarro, & Grijalvo, 2007). The RSE Scale demonstrated
good reliability for the current study (Cronbach’s α= 0.80)
2.3. Procedure
Ethics approval was granted by the Human Research Ethics
Committee and by Australian Catholic University (ACU). Participants
were recruited online via social networking websites (e.g. Facebook)
and through the National School of Psychology Research Participation
System (SONA). After being presented with the Plain Language
Statement (PLS), consent was assumed at commencement of the
questionnaire packet, which included basic demographic questions
and the study measures. Those recruited via SONA were given course
credit incentive to participate in the study, and all other participants
who completed the survey were entered into a draw to win a mini-iPad.
2.4. Data analysis
Means, standard deviations and Pearson correlation coefficients
were calculated for all variables. Mediation analyses were then
conducted to explore whether stress reactivity and self-esteem mediated
the relationship between social anxiety and disordered eating. The
significance of these indirect effects was tested via bootstrapping
procedures. Specifically, the SPSS PROCESS macro was specified to
create a total of 5000 bootstrap samples from the dataset by random
sampling with replacement (Preacher & Hayes, 2008). This generates
the indirect effects and bias-corrected confidence intervals (CI’s). When
the 95% CI’s do not include zero, then the indirect effect is significant.
Partial and full mediation was specified for significant indirect effects.
Full mediation occurs when the relationship between social anxiety and
disordered eating (i.e. the direct effect) is non-significant, while partial
mediation occurs when the relationship between social anxiety and
disordered eating is significant (Preacher & Hayes, 2008). Kappa
squared is reported as the measure of effect size for indirect effects,
where values of around 0.01, 0.09, and 0.25 are considered small,
medium, and large effects, respectively (Preacher & Kelley, 2011).
3. Results
Table 1 presents the means, standard deviations, and correlation
coefficients for each study variable. As can be seen, social anxiety and
disordered eating is significantly and positively related, and both social
anxiety and disordered eating are positively related to the stress
reactivity subscales and negatively related to self-esteem.
Table 2 presents the indirect effect, direct effect, and effect size from
the results of the mediation analyses. As can be seen, self-esteem
(β = −0.12) and reactivity to stress during social conflict (β = 0.14)
partially mediated the relationship between social anxiety and disordered
eating. By contrast, reactivity to stress during social evaluations
(β = 0.08) did not mediate the relationship between social
anxiety and disordered eating.
4. Discussion
Although research has reported consistent links between social
anxiety and disordered eating, less is known about the mechanisms
underlying this relationship. Therefore, the purpose of the current study
was to examine whether stress reactivity and self-esteem mediates the
relationship between social anxiety and disordered eating in a community
samples.
Results from the current study demonstrate that self-esteem and a
reactivity to stress during social conflict – but not during negative social
evaluations – partially mediated the relationship between social anxiety
and disordered eating. These findings suggest that two possible reasons
why socially anxious individuals exhibit elevated symptoms of disordered
eating is through a pervasive negative view of the self and
through a higher response to stress during interpersonal conflict. These
findings are consistent with theoretical perspectives on eating disorders,
including Emotion Regulation theory, Interpersonal theory, and
the Transdiagnostic theory of eating disorders (Ansell et al., 2012;
Fairburn et al., 2003; Hilt et al., 2011; Polivy & Herman, 1993). That is,
the findings support the notion that the link between social anxiety and
disordered eating can be partially explained by difficulty coping with
stress resulting from relationship conflict. Moreover, the findings
demonstrate how low self-esteem and interpersonal conflict are powerful
mechanisms that serve to maintain eating disorder psychopathology,
and highlight the importance of ensuring that these mechanisms
are sufficiently addressed during prevention and intervention programs
(Fairburn, 2008). For example, the findings suggest that evidence based
treatment for eating disorders, such as Cognitive Behaviour Therapy –
Enhanced (CBT-E; Fairburn, 2008) may be more effective by drawing
on strategies from other treatment modalities that have a greater focus
on self-esteem, emotion regulation and interpersonal relationship
strategies.
However, unexpectedly, reactivity to stress during negative social
evaluations did not mediate the relationship between social anxiety and
disordered eating in this study. It is possible that this finding was due to
methodological limitations, where the measure used to assess stress
reactivity to social evaluations, exhibited low reliability. Further, it is
possible that differing findings between reactivity to stress during
negative social evaluations vs. relationship conflict were due to other
underlying mechanisms. For example, perhaps reactivity to stress
during relationship conflict has a stronger influence on the relationship
between social anxiety and disordered eating because some eating
Table 1
Means, standard deviation, and correlation between study variables.
Variable 1 2 3 4 5
1. Social anxiety
2. Disordered eating 0.36⁎⁎⁎
3. Stress reactivity (social
conflict)
0.28⁎⁎⁎ 0.23⁎⁎⁎
4. Stress reactivity (social
evaluations)
0.51⁎⁎⁎ 0.24⁎⁎⁎ 0.51⁎⁎⁎
5. Self-esteem −0.39⁎⁎⁎ −0.24⁎⁎⁎ −0.25⁎⁎⁎ −0.34⁎⁎⁎
Mean 51.27 8.33 6.13 5.61 16.69
Standard deviation 21.16 8.67 2.06 2.32 2.01
⁎⁎⁎ p < 0.001.
Table 2
Results from the mediation analyses.
Pathway Indirect effect
(95% CI)
Direct effect
(95% CI)
ES Type
Social anxiety → SR (social
conflict) → disordered eating
0.04 (0.01,
0.08)
0.11 (0.07,
0.16)
0.04 Partial
Social anxiety → SR (social
evaluations) →disordered
eating
0.04 (−0.02,
0.10)
0.11 (0.06,
0.16)
0.03 None
Social anxiety → self-esteem →
disordered eating
0.05 (0.01,
0.09)
0.11 (0.07,
0.15)
0.05 Partial
Note. Indirect effect refers to standardised values; ES= effect size (Kappa squared);
SR =stress reactivity.
J.L. Ciarma, J.M. Mathew Eating Behaviors 26 (2017) 177–181
179
disorders (i.e. Anorexia Nervosa) are characterised by low body weight
that can be recognised by others, and in turn, elicit concern and care. In
a way, eating disorder symptoms could then also serve the purpose of
non-verbal means to attempt to resolve relationship conflict. However,
this may not be the case for reactivity to negative social evaluations.
Another important finding was that partial rather than full mediation
was observed for self-esteem and reactivity to stress during social
conflict. This demonstrates the importance of discovering the additional
mechanisms that account for the relationship between social anxiety
and disordered eating. Therefore, future research would benefit from
testing a more complex model that takes into account other potential
moderating and mediating variables of the relationship between social
anxiety and disordered eating.
There are limitations to the current study that need to be considered.
The cross-sectional and correlational nature of this study precludes
inferences made about the direction of the relationships
specified and also about causality. Although cross-sectional designs
are an important first-step to understand plausible mechanisms underlying
the relationship between social anxiety and disordered eating,
future longitudinal research is clearly needed to test direction of the
relationships specified in the models present in this study. In addition,
our sample was predominately female (80%) and therefore findings
from the current study may not be generalised to the male population.
It is important for future research to examine the impact of stress
reactivity and self-esteem on social anxiety and disordered eating in
large male samples, as social anxiety and disordered eating is becoming
increasingly prevalent in males (Strother, Lemberg,
Stanford, & Turberville, 2012; Xu et al., 2012). Further, the study was
limited in that participants were recruited online via social media
websites, which may have introduced bias in the sample (e.g. by
attracting those of higher socio-economic status with access to a
computer and internet). Lastly, given that participants could complete
questionnaires in their own time and at a chosen location, the study did
not control other extraneous variables such as distractions, fatigue, and
time pressure.
In sum, low self-esteem and a higher reactivity to stress during
social conflict partially mediated the relationship between social
anxiety and disordered eating in a community sample. These findings
suggest that increasing focus on strategies related to self-esteem and
interpersonal relationships in current treatment approaches to eating
disorders, may enhance their effectiveness. Further longitudinal research
is needed to examine the directionality of the proposed models.
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