Eating Disorders and Social Anxiety

When you have an eating disorder such as anorexia nervosa, bulimia nervosa, or binge-eating disorder (BED), it's not uncommon to have anxiety in situations involving eating in front of others or to have concerns about how others perceive your body in social situations. In some cases, such symptoms could also be signs of another mental health issue, specifically social anxiety disorder (SAD).

People with eating disorders can often have another mental health issue, such as generalized anxiety disorder, post-traumatic stress disorder (PTSD), or obsessive-compulsive disorder (OCD).

However, SAD is consistently found to be the first or second most common anxiety disorder in patients with eating disorders. Some studies have shown that in patients with anorexia nervosa, the rate of SAD is between 16 and 88 percent; for patients with bulimia nervosa, this rate is between 17 and 68 percent. In the one known study that compared levels of social anxiety in patients with BED, it appears that the incidence of social anxiety is elevated in these individuals when compared with healthy controls. Overall, SAD is significantly more common among individuals with eating disorders than among control groups.

What Is Social Anxiety Disorder?

Social anxiety is the fear of social situations. In its most extreme form, it reaches diagnostic criteria for a disorder. Prior to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), this disorder was called “ social phobia”.

SAD is an anxiety disorder involving intense discomfort in social interaction, and fear of being embarrassed, rejected or scrutinized by others. In these situations, people with SAD commonly experience physical sensations such as sweating, blushing, shortness of breath, or nausea. They may avoid or try to escape from these situations.

How Are Eating Disorders and Social Anxiety Disorder Related?

The link between social anxiety and eating disorders makes sense intuitively; anxiety about how one’s self appears to others can lead to an excessive preoccupation with body weight and shape.

It also showed that social appearance anxiety, the fear of one’s appearance being evaluated, specifically predicted eating disorder symptoms including binge eating.

Some of the symptoms of the disorders can be similar. People with eating disorders can have anxiety about eating in front of others. They may fear and avoid eating in social situations and worry about others judging them for what and how they eat. Their body image concerns may also become magnified in social situations. For example, they may fear their body size or shape being judged by others and may avoid certain settings or behave in ways (e.g., inappropriately covering up) to avoid drawing attention.

Treatment for Social Anxiety Disorder and Eating Disorders

Any time a person experiences symptoms of more than one condition, treatment becomes more complicated. There is some evidence that having social anxiety can make eating disorder treatment less effective. Thus, social anxiety must also be addressed in treatment.

Fortunately, there are effective treatments.

Exposure therapy, which involves gradually facing the situations that you fear, is a critical element of CBT for social anxiety disorder.

Research supports the effectiveness of body image exposures more generally and it is possible that some of these exposures indirectly reduce the fear of negative evaluation regarding one’s appearance (social appearance anxiety) by teaching clients to tolerate anxiety related to their bodies in social settings. Addressing perfectionism in treatment can decrease both social anxiety and disordered eating symptoms.

A Word From Verywell

Regardless of whether you qualify for a formal diagnosis of SAD, if you have anxiety about eating in front of others or of dressing a certain way in public, treatment should involve exposure. You can work up slowly from less scary situations to those that are scarier. Fortunately, many therapists who work with eating disorders are familiar with the treatment of other commonly co-occurring conditions.