The Relationship Between Eating Disorders & Anxiety

By Kamila Cass, PhD, CEDS-C

Anxiety and eating disorders are often closely linked. Up to 62% of individuals with eating disorders also have an anxiety disorder. Feelings of anxiety can trigger food restriction, binge eating or purging. Constant worry about food, body image and weight can further fuel the eating disorder. Social anxiety and generalized anxiety disorder are two of the most common anxiety disorders seen in those with eating disorders. Addressing both anxiety and eating behaviors in treatment is crucial for effective treatment, helping individuals develop healthier coping strategies and emotional regulation skills.

Anxiety & Eating Disorders

Research demonstrates that up to 95% of people diagnosed with an eating disorder also receive a diagnosis for at least one more psychiatric disorder (dual diagnosis).1 The most common co-occurring mental health conditions seen with eating disorders are anxiety disorders, withup to 62% of individuals with eating disorders also experience an anxiety disorder.1-3

Some of the most common co-occurring anxiety disorders in eating disorder patients are:

  • Social anxiety disorder
  • Generalized anxiety disorder

Social Anxiety Disorder

Social anxiety disorder (SAD) is a disproportionate fear or anxiety regarding social situations, with common situations including social interactions, being observed or performing.4 This fear and anxiety are associated with symptoms like:

  • Avoidance of social situations
  • Anticipating the worst outcomes or consequences
  • Blushing or sweating
  • Upset stomach or nausea
  • Trembling
  • Fast heartbeat

Social anxiety disorder & eating disorders

Up to 42% of individuals with anorexia nervosa will experience symptoms that meet clinical criteria for social anxiety disorder (SAD), with even more experiencing subclinical symptoms.3 However, this number may be higher, as it only includes patients attending treatment programs. Those with social anxiety may hesitate to seek treatment because of their fears and worries.

Appearance anxiety

Social appearance anxiety (feeling distress or fear about being negatively judged or evaluated based on one’s physical appearance) may contribute to an eating disorder. Social appearance anxiety is positively correlated with measures of social anxiety as well as negative body image and body mass index (BMI), drive for thinness and body dissatisfaction in women with eating disorders.5,6

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is excessive anxiety and worry about a number of events or activities with difficulty controlling the worry.4 The anxiety and worry are associated with the following symptoms:

  • Restlessness or feeling on edge
  • Being easily fatigued
  • Difficulty concentrating or mind going blank
  • Irritability
  • Muscle tension
  • Sleep disturbance

Generalized anxiety disorder & eating disorders

Up to 30% of individuals with anorexia nervosa and bulimia nervosa have generalized anxiety disorder.7 There may also be a relationship between the severity of disordered eating behaviors and generalized anxiety disorder. There is a higher prevalence of GAD in patients who restrict food, excessively exercise or have a low body mass index (BMI).8

Perfectionism & other shared traits

There are several clinical features and risk factors that are found in both eating disorders and in GAD. Intense, persistent and overwhelming anxiety is the defining feature of generalized anxiety disorder, and this is mirrored in eating disorders like anorexia nervosa and bulimia nervosa through an intense fear or anxiety regarding weight gain and body shape.9 Perfectionism, rigidity of daily living and meticulousness are also noted in both individuals with eating disorders and individuals with generalized anxiety disorder.9

Order of onset

Studies find around 70% of patients with an eating disorder note that an anxiety disorder preceded their eating disorder, suggesting that anxiety disorders may contribute to the development of an eating disorder.3

Treating co-occurring anxiety disorders & eating disorders

Eating disorders can be a manifestation of attempts to cope with anxiety symptoms. Anxiety symptoms can also be a consequence of the eating disorder but make it more difficult to take the steps necessary to recovery from an eating disorder. Obtaining treatment for both an anxiety disorder and an eating disorder can be invaluable in the recovery process. These therapies have been shown to help.

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is a form of psychotherapy that focuses on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop effective coping mechanisms.

CBT helps build awareness of negative thought patterns that can be present in those with both eating disorders and anxiety. CBT helps patients learn how intercept these thoughts so they can view challenging situations more clearly, respond to them in a more effective way and create more productive and positive thought patterns in their place.

Acceptance & commitment therapy

Acceptance and commitment therapy (ACT) is an evidence-based form of psychotherapy that aims to develop psychological flexibility instead of avoiding, eliminating or suppressing undesirable experiences like anxiety.

ACT can help patients to accept their anxious and eating disorder thoughts rather than trying to fight or control them. Instead of fighting a losing battle, ACT can help patients commit to actions aligned with an individual’s personal values, allowing them to live a more fulfilling life despite their anxiety and eating disorder.

Other therapies

The gold standard to treat anxiety disorders is talk therapy plus psychotropic medication, followed by just talk therapy and then just psychotropic medication. It can be helpful to see both a psychiatrist and a therapist to learn the most effective strategies.

Recovery from anxiety disorders and eating disorders is possible with the help of an experienced treatment team. Everyone’s journey to recovery is unique, and some patients benefit from certain therapies more than others. There are a variety of other psychotherapies that can help with eating disorders and other co-occurring conditions.

Learn more about psychotherapy for anxiety disorders and eating disorders.

Find Help for Dual Diagnosis

Living with both an eating disorder and an anxiety disorder can feel especially overwhelming, but you don’t have to navigate it alone. Integrated care that addresses both conditions at the same time is essential for lasting recovery. With the right support team and evidence-based treatment, recovery is possible.

References:

  1. Hambleton, A., Pepin, G., Le, A., Maloney, D., Aouad, P., Barakat, S., Boakes, R. A., Brennan, L., Bryant, E., Byrne, S. M., Caldwell, B., Calvert, S., Carroll, B., Castle, D. J., Caterson, I. D., Chelius, B., Chiem, L., Clarke, S., Conti, J., . . . Maguire, S. (2022). Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature. Journal of Eating Disorders, 10(1). https://doi.org/10.1186/s40337-022-00654-2
  2. Eating Disorders. (n.d.). National Institute of Mental Health (NIMH). https://www.nimh.nih.gov/health/statistics/eating-disorders
  3. Swinbourne, J., Hunt, C., Abbott, M. J., Russell, J., St Clare, T., & Touyz, S. (2012). The comorbidity between eating disorders and anxiety disorders: Prevalence in an eating disorder sample and anxiety disorder sample. Australian and New Zealand Journal of Psychiatry, 46(2), 118–131. https://doi.org/10.1177/0004867411432071
  4. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
  5. Claes, L., Hart, T. A., Smits, D., Van Den Eynde, F., Mueller, A., & Mitchell, J. E. (2011). Validation of the social appearance anxiety scale in female eating disorder patients. European Eating Disorders Review, 20(5), 406–409. https://doi.org/10.1002/erv.1147
  6. Koskina A, Van Den Eynde F, Meisel S, Campbell IC, Schmidt U. Social appearance anxiety and bulimia nervosa. Eating and Weight Disorders. 2011;16:e142–145. doi: 10.1007/BF03325321. https://pmc.ncbi.nlm.nih.gov/articles/PMC5112114/
  7. Halmi, K. A. (1991). Comorbidity of psychiatric diagnoses in anorexia nervosa. Archives of General Psychiatry, 48(8), 712. https://doi.org/10.1001/archpsyc.1991.01810320036006
  8. Thornton, L. M., Dellava, J. E., Root, T. L., Lichtenstein, P., & Bulik, C. M. (2011). Anorexia nervosa and generalized anxiety disorder: Further explorations of the relation between anxiety and body mass index. Journal of Anxiety Disorders, 25(5), 727–730. https://doi.org/10.1016/j.janxdis.2011.03.010
  9. Schaumberg, K., Reilly, E. E., Gorrell, S., Levinson, C. A., Farrell, N., Brown, T. A., Smith, K. E., Schaefer, L. M., Essayli, J. H., Haynos, A. F., & Anderson, L. (2021). Conceptualizing eating disorder psychopathology using an anxiety disorders framework: Evidence and implications for exposure-based clinical research. Clinical Psychology Review, 83, 101952. https://doi.org/10.1016/j.cpr.2020.101952
Written by
Kamila Cass, PhD, CEDS

Kamila Cass, PhD, CEDS-C

Kamila Cass, PhD, CEDS-C, is a Licensed Clinical Psychologist at the ACUTE Center for Eating Disorders and Severe Malnutrition, where she has worked with patients with eating disorders since 2021. She…

ACUTE Earns Prestigious Center of Excellence Designation from Anthem
In 2018, the ACUTE Center for Eating Disorders & Severe Malnutrition at Denver Health was honored by Anthem Health as a Center of Excellence for Medical Treatment of Severe and Extreme Eating Disorders. ACUTE is the first medical unit ever to achieve this designation in the field of eating disorders. It comes after a rigorous review process.

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