Eating Disorders and Social Anxiety Disorder

Woman hiding and eating a chocolate bar.
Social anxiety and eating disorders show significant overlap. Getty / Anthony Lee

Social anxiety disorder (SAD) and eating disorders may naturally exist together in the same person. If you already suffer with SAD, it is important to understand your risk for eating disorders as well.

Eating Disorders

Historically, two main types of eating disorders have been recognized: anorexia nervosa and bulimia nervosa. In the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), binge eating disorder was first defined.

People with anorexia nervosa have an intense fear of becoming overweight. As a result, they severely restrict food intake, often bringing themselves to the brink of starvation.

People with bulimia nervosa engage in a binge-purge cycle. They will eat large amounts of food and then take measures to get it out of their system such as vomiting, taking laxatives, abusing diuretics, or exercising excessively.

Those with binge eating disorder engage in the binge without the purge. These individuals have recurring episodes of binge eating, in which they eat to a point that becomes uncomfortable. They may eat alone for fear of embarrassment over how much they are eating. Although some people with this disorder may be overweight, it is not necessary for a diagnosis.

Social Anxiety Disorder

Individuals with social anxiety disorder have significant and persistent fears of situations in which embarrassment, rejection, or scrutiny are possible.

They most often feel physical symptoms of anxiety in these situations, and may avoid, escape, or endure them with intense distress.

Distinguishing SAD from Eating Disorders

Eating disorders are sometimes diagnosed in the same people who suffer from social anxiety disorder (SAD). In addition, some symptoms of SAD appear very similar to the symptoms of eating disorders.

Fear of eating in public is a symptom common of both SAD and eating disorders, but the specific types of behavior and the motivation underlying the behavior are quite different.

People with anorexia are concerned about being judged for overeating or being overweight, and may develop unusual patterns or rituals such as shifting food around on their plate or cutting food into tiny pieces.

People with SAD are not concerned with eating behavior directly. They are intensely worried that others will notice the symptoms of their anxiety while eating, such as trembling hands or spilled food. People with SAD usually have a range of social fears in addition to the fear of eating in front of others, while those with eating disorders tend to report few other social anxieties.

How Often Do Anxiety Disorders and Eating Disorders Co-occur?

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 criteria. The results of the study showed that about two-thirds of those who had an eating disorder also suffered from an anxiety disorder.

Forty percent of the study participants were diagnosed as having obsessive-compulsive disorder (OCD) in addition to an eating disorder, and 20% were diagnosed with SAD. Most of those with both an anxiety disorder and an eating disorder reported that their anxiety symptoms came first.

In a 2012 study of 152 women presenting for treatment of an eating disorder, 65% also met criteria for an anxiety disorder; of those, for 69% the anxiety disorder preceded the eating disorder.

Social phobia was the most frequent diagnosis (42%). Finally, 13.5% of the women presenting for an anxiety disorder also had an eating disorder. Possibly—these women were at risk for a later eating disorder that had not yet developed.

What is Your Risk?

If you have been diagnosed with SAD, you may be more at risk for developing an eating disorder. The connection between SAD and eating disorders is still being investigated; however, it is believed that serotonin (the brain chemical involved in SAD), may be partly responsible for eating disorders.

Being overly preoccupied with being perceived negatively by others also may make you more vulnerable to becoming obsessed with reaching an ideal body weight.

People diagnosed with SAD should become familiar with the symptoms of eating disorders and monitor their own thoughts and behaviors about body image, weight, and food.

How are SAD and Eating Disorders Treated?

If you have been diagnosed with both SAD and an eating disorder, your treatment will need to target both the issues surrounding food, weight and body image, as well as general social anxiety issues.

Although a combination of medication and psychotherapy is usually recommended for treating patients with SAD, those who are severely underweight due to anorexia may not respond to medication until their body weight returns to a normal range.

Your doctor will be able to recommend the best course of action to treat both disorders separately while also taking into account the complications of having both disorders at the same time.

Sources:

Bandelow B, Stein D, eds. Social anxiety disorder. New York: Marcel Dekker; 2004.

Kaye WH, Bulik CM, Thornton L, Barbarich N, Masters K. Comorbidity of anxiety disorders with anorexia and bulimia nervosa. American Journal of Psychiatry. 2004; 161(12): 2215-21.

Phoa EB, Wasmer Andrews L. If your adolescent has an anxiety disorder: An essential resource for parents. New York: Oxford University Press; 2006.

Swinbourne J, Hunt C, Abbott M, Russell J, St Clare T, Touyz S. The comorbidity between eating disorders and anxiety disorders: prevalence in an eating disorder sample and anxiety disorder sample. Aust N Z J Psychiatry. 2012 Feb;46(2):118-31.

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