Social anxiety in anorexia and bulimia nervosa: the mediating role of shame

Objective: The close relationship between social anxiety and eating disorders has attracted considerable scholarly attention in recent years. Shame has been identified as the key emotional symptom in the link between social anxiety and social phobia. While shame is commonly recognized as a meaningful construct for understanding eating disorders, empirical research into this issue has been lacking. Thus, the objective of this study was to determine the strength of influence shame and social anxiety have in the psychopathology of anorexia nervosa and bulimia nervosa compared with other clinical groups. Furthermore, the issue of whether shame can account for clinical group differences in the experienced levels of social anxiety was examined. Method: The sample consisted of 120 female inpatients, divided into four groups of 30 according to individual diagnoses: anorexia nervosa, bulimia nervosa, anxiety disorders and depression. The Social Interaction Anxiety Scale (SIAS), the Social Phobia Scale (SPS) and the Internalized Shame Scale (ISS) were used to measure the target constructs for this investigation. Results: Patients with anorexia and bulimia nervosa have higher scores in internalized global shame than patients with anxiety disorders and depressions. In contrast to anorectic patients, however, patients with bulimia also have higher scores than the other two groups in the area of social performance anxiety; they also differ significantly from the anxiety disorders in terms of interaction anxiety. Once shame was partialled out, group differences of social anxiety were shown to disappear. Discussion: Both shame and social anxiety have to be regarded as important influencing factors in anorexia and bulimia nervosa, with shame making a significant contribution to the explanation of social anxieties. The interaction between shame and social anxiety as well as its relevance for eating disorders are discussed. With regards to the therapeutic implications, it would seem reasonable not only to focus on treating shame affect but also to specifically adopt a therapeutic strategy targeting social anxiety fears. Copyright © 2006 John Wiley & Sons, Ltd.

[1]  M. Martínez-González,et al.  Neuroticism and low self-esteem as risk factors for incident eating disorders in a prospective cohort study. , 2003, The International journal of eating disorders.

[2]  G. Waller,et al.  Reported sexual abuse and bulimic psychopathology among nonclinical women: the mediating role of shame. , 2002, The International journal of eating disorders.

[3]  A. Wells.  A cognitive model of social phobia , 1995 .

[4]  R. Goodwin,et al.  Social anxiety as a barrier to treatment for eating disorders. , 2002, The International journal of eating disorders.

[5]  Y. Lecrubier,et al.  Anxiety disorders in anorexia nervosa and bulimia nervosa: co-morbidity and chronology of appearance , 2000, European Psychiatry.

[6]  E. Schumann,et al.  [Results of psychodynamic inpatient psychotherapy in relation to diagnosis]. , 2004, Zeitschrift fur Psychosomatische Medizin und Psychotherapie.

[7]  E. S. Frank,et al.  Shame and guilt in eating disorders. , 1991, The American journal of orthopsychiatry.

[8]  J. Rodin,et al.  The social self in bulimia nervosa: public self-consciousness, social anxiety, and perceived fraudulence. , 1993, Journal of abnormal psychology.

[9]  E. Nickel,et al.  Development of Scales to Screen for Eight Common Psychiatric Disorders , 2005, The Journal of nervous and mental disease.

[10]  E. Stice.  Risk and maintenance factors for eating pathology: a meta-analytic review. , 2002, Psychological bulletin.

[11]  J. Tangney,et al.  The Relation of Shame and Guilt to Eating Disorder Symptomatology , 1995 .

[12]  C. Meyer,et al.  Social anxiety and coping strategies in the eating disorders. , 2003, Eating behaviors.

[13]  S. Sohlberg,et al.  Internalized shame and early interactions characterized by indifference, abandonment and rejection: replicated findings , 2002 .

[14]  S. Hollon,et al.  Cognitive Therapy for Depression , 1990 .

[15]  D. Barlow,et al.  Etiology and treatment of social anxiety: a commentary. , 2004, Journal of clinical psychology.

[16]  R. Heimberg,et al.  Factor structure of the Social Interaction Anxiety Scale and the Social Phobia Scale. , 1998, Behaviour research and therapy.

[17]  B. Fredrickson,et al.  A Mediational Model Linking Self-Objectification, Body Shame, and Disordered Eating , 1998 .

[18]  Deborah C. Beidel,et al.  An analysis of social anxiety in anorexic, bulimic, social phobic, and control women , 1991 .

[19]  P. Gilbert.  The relationship of shame, social anxiety and depression: the role of the evaluation of social rank , 2000 .

[20]  H. Irwin,et al.  Shame and guilt in women with eating-disorder symptomatology. , 2000, Journal of clinical psychology.

[21]  K. Brownell,et al.  Shame and severity of bulimic symptoms. , 2002, Eating behaviors.

[22]  M. Flament,et al.  Comorbidity between eating disorders and anxiety disorders: a review. , 2002, The International journal of eating disorders.

[23]  S. Srikameswaran,et al.  Perfectionism and eating disorders. , 2002 .

[24]  G. Waller,et al.  Social Anxiety and Agoraphobia in the Eating Disorders:: Associations With Core Beliefs , 2004, The Journal of nervous and mental disease.

[25]  T. Heidenreich,et al.  Die Erfassung sozialer Phobie durch die Social Interaction Anxiety Scale (SIAS) und die Social Phobia Scale (SPS) , 1999 .

[26]  J. Clarke,et al.  Exposure and cognitive restructuring for social phobia: A controlled study , 1989 .

[27]  Mingyi Qian,et al.  Predicting depressive symptoms with a new measure of shame: The Experience of Shame Scale. , 2002, The British journal of clinical psychology.

[28]  B. Andrews.  Bodily shame in relation to abuse in childhood and bulimia: a preliminary investigation. , 1997, The British journal of clinical psychology.

[29]  C. Fairburn,et al.  Clinical perfectionism: a cognitive-behavioural analysis. , 2002, Behaviour research and therapy.

[30]  A. Beck,et al.  Syndrome comorbidity in patients with major depression or dysthymia: prevalence and temporal relationships. , 1990, The American journal of psychiatry.

[31]  I. M. Evans,et al.  The underlying psychopathology of eating disorders and social phobia: a structural equation analysis. , 2001, Eating behaviors.

[32]  Lynn E. Alden,et al.  International handbook of social anxiety : concepts, research and interventions relating to the self and shyness , 2001 .

[33]  P. Gilbert.  What is shame? Some core issues and controversies. , 1998 .