Diagnostic, clinical, and personality correlates of food anxiety during a food exposure in patients diagnosed with an eating disorder
Eating disorders are characterized by high levels of anxiety, especially while eating. However, little is known about anxiety experienced during meals and specifically what other variables may impact such anxiety.
We sought to further quantify and understand the relationship between food anxiety, eating disorders, and related correlates (e.g., comorbid diagnoses, personality).
In the current study [N = 42 participants diagnosed with an eating disorder (n = 36 participants with anorexia nervosa)], we quantified anxiety before, during, and after a meal using data from a food exposure session in a partial hospital eating disorder center. We examined diagnostic, personality, and clinical factors as correlates of food anxiety.
Participants were more likely to experience higher food anxiety if they had a current diagnosis of major depression, obsessive–compulsive disorder, or post-traumatic stress disorder (PTSD). Concern over mistakes was the strongest and most consistent correlate of food anxiety regardless of time during the meal that anxiety was assessed. Other significant correlates were fear of positive evaluation, social appearance anxiety, BMI, and trust.
These findings show how diagnoses, perfectionism (concern over mistakes), and other correlates relate to anxiety during meals. Food exposure interventions may benefit from personalizations that address these factors.
Level of evidence
IV Evidence from a randomized control trial, but from the first session before effects of the design would be present.
KeywordsFear of food Exposure therapy Anorexia nervosa Social appearance anxiety Perfectionism
This research was supported by NIMH F31-MH096433 to Cheri A. Levinson. The funding source had no role in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.
Compliance with ethical standards
Conflict of interest
All authors declare that they have no conflict of interest.
The Washington University IRB approved all procedures in this study and all the procedures performed in the current study were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendment.
Informed consent was obtained for experimentation with human subjects.
- 2.American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th edn. American Psychiatric Association, WashingtonGoogle Scholar
- 5.Cardi V, Esposito M, Clarke A, Schifano S, Treasure J (2015) The impact of induced positive mood on symptomatic behaviour in ED. An experimental, AB/BA crossover design testing a multimodal presentation during a test-meal. Appetite 87:192–198. https://doi.org/10.1016/j.appet.2014.12.224 Google Scholar
- 6.Cardi V, Leppanen J, Mataix-Cols D, Campbell IC, Treasure J (2018) A case series to investigate food-related fear learning and extinction using in vivo food exposure in anorexia nervosa: a clinical application of the inhibitory learning framework. Eur Eating Disord Rev. https://doi.org/10.1002/erv.2639 (Epub ahead of print) Google Scholar
- 9.Frost RO, Marten P, Lahart C, Rosenblate R (1990) The dimensions of perfectionism. Cogn Ther Res 14(5):449–468Google Scholar
- 10.Garner DM, Olmstead MP, Polivy J (1983) Development and validation of a multidimensional eating disorder inventory for anorexia nervosa and bulimia. Int J ED 2(2):15–34. https://doi.org/10.1002/1098-108X(198321)2:2%3C15::AID-EAT2260020203%3E3.0.CO;2-6 Google Scholar
- 15.Handley AK, Egan SJ, Kane RT, Rees CS (2015) A randomised controlled trial of group cognitive behavioural therapy for perfectionism. Behav Res Ther 68:37–47Google Scholar
- 17.Heimberg RC, Brozovich FA, Rapee RM (2010) A cognitive behavioral model of social anxiety disorder: Update and extension. In: Hofmann SG, DiBartolo PM (eds) Social anxiety: clinical, developmental, and social perspectives. Academic Press, Cambridge, pp 395–422Google Scholar
- 18.Johnson JA, Briggs SR, Hogan R (1997) Handbook of personality psychology. Elsevier, AmsterdamGoogle Scholar
- 19.Kaplan DM (1995) A validity study of the subjective unit of discomfort (SUD) score. Meas Eval Counsel Dev 27(4):195–199Google Scholar
- 20.Kaye WH, Bulik CM, Thornton L, Brbarich N, Masters K et al (2004) Comorbidity of anxiety disorders with anorexia and bulimia nervosa. Am J Psychiatry 161:2215–2221Google Scholar
- 22.Koskina A, Van den Eynde F, Meisel S, Campbell IC, Schmidt U (2011) Social appearance anxiety and bulimia nervosa. Eat Weight Disord 16(2):e142–e145Google Scholar
- 23.Koskina A, Campbell IC, Schmidy U (2013) Exposure therapy in ED revisited. Neurosci Biobehav Rev 37:193–208Google Scholar
- 25.Lecrubier Y, Sheehan D, Weiller E, Amorim P, Bonora I, Sheehan KH, Dunbar GC (1997) The Mini International Neuropsychiatric Interview (MINI). A short diagnostic structured interview: reliability and validity according to the CIDI. Eur Psychiatry 12(5):224–231. https://doi.org/10.1016/S0924-9338(97)83296-8 Google Scholar
- 30.Levinson CA, Rodebaugh TL (2014) Negative social-evaluative fears produce social anxiety, food intake, and body dissatisfaction. Clin Psychol Sci 3(5):744–757Google Scholar
- 31.Levinson CA, Rodebaugh TL, Fewell L, Kass AE, Riley EN, Stark L et al (2015) D-cycloserine facilitation of exposure therapy improves weight regain in patients with anorexia nervosa: a pilot randomized controlled trial. J Clin Psychiatry 76(6):e787–e793Google Scholar
- 32.Levinson CA, Rodebaugh TL, White EK, Menatti AR, Weeks JW, Iacovino JM, Warren CS (2013) Social appearance anxiety, perfectionism, and fear of negative evaluation: Distinct or shared risk factors for social anxiety and ED? Appetite 67:125–133. https://doi.org/10.1016/j.appet.2013.04.002 Google Scholar
- 34.Mattick RP, Clarke JC (1998) Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behav Res Ther 36(4):455–470Google Scholar
- 36.Murray SB, Loeb Kl, Le Grange D (2016) Dissecting the core fear in anorexia nervosa: can we optimize treatment mechanisms? JAMA Psychiatry 73:891–892Google Scholar
- 37.Murray SB, Treanor M, Liao B, Loeb KL, Griffiths S, Le Grange D (2016) Extinction theory and anorexia nervosa: deepening therapeutic mechanisms. Behav Res Ther 87:1–10Google Scholar
- 39.Pla-Sanjuanelo J, Ferrer-García M, Vilalta-Abella F, Riva G, Dakanalis A, Ribas-Sabaté J et al (2017) Testing virtual reality-based cue-exposure software: which cue-elicited responses best discriminate between patients with eating disorders and healthy controls? Eating Weight Disord Stud Anorexia Bulimia Obes. https://doi.org/10.1007/s40519-017-0419-4 (Epub ahead of print) Google Scholar
- 40.Rosenthal R, Cooper H, Hedges LV (1994) Parametric measures of effect size. Handb Res Synth 621:231–244Google Scholar
- 47.Steinglass J, Sysko R, Schebendach J, Broft A, Strober M, Walsh BT (2007) The application of exposure therapy and d-cycloserine to the treatment of anorexia nervosa: a preliminary trial. J Psychiatric Pract 13(4):238–245. https://doi.org/10.1097/01.pra.0000281484.89075.a8 Google Scholar
- 48.Strober M, Freeman R, Lampert C, Diamond J (2007) The association of anxiety disorders and obsessive compulsive personality disorder with anorexia nervosa: evidence from a family study with discussion of nosological and neurodevelopmental implications. Int J ED 40:S46–S51Google Scholar
- 51.White HJ, Haycraft E, Wallis DJ, Arcelus J, Leung N, Meyer C (2015) Development of the Mealtime Emotions Measure for Adolescents (MEM-A): gender differences in emotional responses to family mealtimes and eating psychopathology. Appetite 85:76–83. https://doi.org/10.1016/j.appet.2014.11.011 Google Scholar
- 52.Wolpe J (1988) Subjective anxiety scale. Dict Behav Assess Tech 455–457Google Scholar
- 53.Yilmaz Z, Gottfredson NC, Zerwas SC, Bulik CM, Micali N (2018) Developmental premorbid body mass index trajectories of adolescents with eating disorders in a longitudinal population cohort. J Am Acad Child Adolesc Psychiatry. https://doi.org/10.1016/j.jaac.2018.11.008 (Epub ahead of print) Google Scholar