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 Provisional chapter
Chapter 5

Anxiety and Eating Disorders in Adult Women

Anxiety and Eating Disorders in Adult Women

Annie Aimé, Tanya Guitard and Lise Grousseaud

Annie Aimé, Tanya Guitard and Lise Grousseaud
Additional information is available at the end of the chapter
Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/65249

Abstract
Anxiety disorders are frequently reported by women diagnosed with eating disorders
EDs . Although this association is long established and rather frequent, the role of
anxiety in the onset and maintenance of eating disorders still has to be beter under‐
stood. ”y doing so, engagement in treatment and eicacy of the interventions used will
be improved. Thus, the present book chapter aims at investigating anxiety comorbidity
in women diagnosed with an ED. First, the prevalence rates of anxiety disorders AD
in ED samples and similarities and diferences between both disorders are presented.
Then, the chronology of onset of both disorders and possible explanations of their
mechanisms of association are discussed. Finally, treatment considerations are covered.

Keywords: anxiety, eating disorders, anxiety disorders, comorbidity, prevalence rates,

chronology, treatment

. Introduction

Comorbidity with other mental health disorders is frequently found in individuals with eating
disorders EDs , mood, and anxiety disorders ADs being the most commonly reported [ , ].
In ED patients, anxiety and stress have been linked to binge and restrictive eating, as well as
vomiting and laxative abuse [ , ]. ED women report high levels of anxiety in a wide variety
of eating situations and tend to resort to numerous behaviours aiming at reducing or managing
anxiety [ ]. Available past research interested in the relationship between anxiety and ED has
mainly focused on prevalence rates of ADs in EDs [ ]. However, there is still a need to beter
understand the nature of this frequent association [ ].

Additionally, the comorbidity of AD has been shown to negatively impact ED treatment as the
presence of AD accentuates the severity of the symptomatology, which can complicate

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons
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Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,
and reproduction in any medium, provided the original work is properly cited.
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84 Eating Disorders - A Paradigm of the Biopsychosocial Model of Illness

treatment formulation [ ], maintain ED, and represent a barrier for help‐seeking, engagement,
and compliance in therapy [ , ]. For instance, as a trait present in many women with ED,
anxiety has been associated with higher ED psychopathology and has shown to afect the
course of the ED through a longer duration of the illness, a higher number of hospitalizations,
and premature treatment termination [ , ]. Given the potential treatment complications
related to a dual diagnosis of AD and ED, treatment strategies taking this comorbidity into
account and aiming to provide adequate care for women having to deal with such dual
diagnoses must be underscored. Thus, this chapter irst yields a review of the estimated
prevalence rates of ADs in EDs and of their chronology of onset. Second, it provides insights
on the nature of the association between ADs and EDs, and lastly it highlights treatment
considerations.

. Strength of the association

The link between anxiety and ED is observable in the relatively high prevalence of comorbid
AD in people with ED. According to the few reviews interested in the comorbidity of both
disorders [ , , ], there is substantial variation in the estimated prevalence rates of anxiety in
adults with EDs and these rates mostly focus on women. The variations in the strength of the
association between ADs and EDs are mostly due to sampling e.g. small number of partici‐
pants, participants from the community or from specialized treatment centers and methodo‐
logical issues e.g. use of nonstructured or standardized instruments, interviews or
questionnaires, number of ADs considered, lack of statistical power, varied inclusion and
exclusion criteria, no control group, and retrospective study devise [ , – ]. They are also
atributable to diagnostic particularities such as overlaps in symptoms between disorders and
changes in the nosography from one version of the Diagnostic and Statistical Manual of Mental
Disorders DSMs to the other [ ]. Finally, estimates of prevalence rates are further complicated
by the fact that, when medication is prescribed to reduce anxiety symptoms in patients with
ED, AD may be underdiagnosed [ ].

. . Prevalence rates of ADs in EDs

According to Swinbourne and her colleagues [ , ], lifetime prevalence rates of at least one
comorbid anxiety disorder ranges from to % in participants with anorexia nervosa and
from to % in those with bulimia nervosa [ , ]. Lifetime diagnoses of AD are signiicantly
more frequent in AN and ”N samples than in control groups [ ]. Although less often assessed,
ADs have also been reported in obese individuals who binge eat, with a prevalence rate of
about % for both generalized anxiety disorder [ ] and social anxiety disorder [ ].

Available prevalence rates should be taken with caution given that they were obtained by using
older versions of the DSM e.g. DSM‐III, III‐R, IV, and IV‐R and that they rely on various
sources of patients. Consequently, while considering prevalence comorbidity rates between
ADs and EDs, one must keep in mind that estimates based on the DSM‐ are still lacking
they include obsessive compulsive disorders, a particularly highly correlated disorder in
 Anxiety and Eating Disorders in Adult Women 85
http://dx.doi.org/10.5772/65249

AN, which is not considered as an AD anymore [ ] and higher rates of comorbidity are
usually found in samples issued from clinical setings e.g. inpatient and outpatient eating
disorders samples , in which higher psychological distress and multiple diagnoses are more
prevalent [ , ].

Among the DSM‐ AD diagnoses, social anxiety disorder SAD and generalized anxiety
disorder GAD have been the most frequently and systematically associated with ED across
studies, any ED type confounded [ ]. In AN samples, GAD is the most frequent AD diagnosis
reported, followed by SAD and agoraphobia [ , ]. In ”N patients, SAD is the most frequent
AD in ”N patients, and GAD follows while agoraphobia remains the third most frequently
reported AD [ ]. Compared to women without ED, those with AN and ”N, respectively, have
a . and . times greater risk of being diagnosed with GAD [ ]. SAD is also signiicantly more
frequent in women with AN and ”N than in control groups and has been particularly linked
to an increased risk of binge eating [ , , ]. Agoraphobia for its part appears to be more likely
to be reported by women with binge‐purge AN and ”N than by controls [ ].

. . Similarities between ADs and EDs

Some diagnostic criteria found in the DSM‐ for ED [ ] refer to anxiety. For instance, an
intense fear of gaining weight” or of becoming fat” has to be present in patients with AN,
and a sense of lack of control over eating” has to be reported by patients with ”N and binge‐
eating disorder [ ]. This criterion resembles those of ADs, for example, fear or anxiety of
social setings” found as the primary requirement for SAD. Furthermore, as stated by Webb
and colleagues [ ], items referring to anxious dimensions of eating such as a fear of losing
control, a fear of gaining weight and intense concerns over shape and weight are also used in
well‐known measures of disordered eating like the Eating Disorder Examination [ ].

Additionally, it has been showed that women with ”N present similar anxiety symptoms than
patients with GAD, with worrying, tension pains, tiredness, restlessness, avoidance of anxiety,
social withdrawal, and lack of conidence being equally frequent in both groups [ ].

. . Diferences between ADs and EDs

On the contrary, some diferences have been highlighted between EDs and ADs. As an
example, Steere et al. [ ] showed that panic atacks, muscular and nervous tensions, as well as
free‐loating anxiety and anxious foreboding were signiicantly more prevalent in participants
with GAD than in ”N women.

Diferences between ADs and EDs are particularly important to consider for diagnostic
purposes. In fact, anxiety limited to ED‐speciic themes must be distinguished from non‐ED‐
speciic anxiety [ ]. In many women diagnosed with EDs, the anxiety symptoms they
experience are speciic to their ED. In other words, their anxiety symptoms mostly focus on
eating, weight, and shape concerns as well as on fear of weight gain or a feeling of being fat
[ , ]. These patients also typically fear being exposed to high‐calorie foods and avoid
exhibiting their body in public. When their anxiety is ED‐speciic and when they succeed in
controlling their weight and eating, women with EDs do not experience anxiety [ ] and the
86 Eating Disorders - A Paradigm of the Biopsychosocial Model of Illness

clinician cannot conclude in a comorbid AD. However, when a nonspeciic anxiety focus is
found, such as a general fear of failure or a social anxiety in any public situations, a comorbid
AD must be suspected [ ].

. Chronology of onset

Various temporal sequences have been suggested for the comorbidity of AD and ED [ , ].
First, anxiety may be a risk factor for ED. This pathway of association in which anxiety tends
to appear prior to the onset of ED has received the most research support [ , , , – ].
According to Godart and colleagues [ ], between . and . % of women seeking help for
AN and between . and . % of those with a ”N diagnosis had developed an AD prior to
their ED. More recently, Swinbourne and colleagues [ ] found that the larger proportion of
their sample of women in inpatient treatment % and in outpatient treatment % for ED
had had an AD before the onset of their ED. Studies that support this developmental sequence
have suggested that excessive fears about events or situations as well as anxiety about social
evaluation reported in childhood could predispose to intense preoccupations with weight,
shape, and food in late adolescence and young adulthood [ ] an anxious trait, independent
of nutritional state, would be underlying in ED patients [ , ] childhood anxiety
negatively inluences the course and outcome of EDs [ ] and anxiety symptoms tends to
persist after recovery from an ED [ , , ] and to be signiicantly higher in recovered women
from ED than in healthy controls [ ].
Second, anxiety may be secondary to an ED. This chronology of onset has been reported by
% of inpatient and by % of outpatient ED women [ ]. This pathway suggests that ED
could produce or exacerbate anxiety in some women. It is mainly supported by evidences that
anxiety tends to increase following starvation [ , ] and by the indings that, in AN patients,
anxiety symptomatology tends to decrease over the course of ED treatment as they regain
weight and to be signiicantly lower than in acutely ill patients [ , ].
Third, AD and ED may both result from a common aetiology or a shared vulnerability [ , ].
In this developmental model of comorbidity, it is supposed that when one of these disorders
is activated, the vulnerability to the other is increased [ ]. This model is supported by indings
showing that anxiety and elevated rates of ADs are present in irst‐degree relatives and family
of origin of women who developed an ED [ , ]. Other overlapping risk factors like early
childhood experiences [ ] or negative afect [ ] could contribute to the high comorbidity rates
between both disorders. Along that line, it has been suggested that childhood negative
experiences give rise to maladaptive schemas, which negatively inluence the interpretation
of events and experiences and can accentuate the risk of adopting anxiety‐ and eating‐related
symptomatic behaviours [ ]. With regard to negative afect, Schneider et al. suggested that
anxious individuals could use eating as a means of regulating negative emotions [ ].
In further support for the shared vulnerability model, Levinson and Rodebaugh [ ] found that
social appearance and fear of negative evaluation were associated with a higher risk of
experiencing ED and SAD. While social appearance anxiety refers to a fear of being negatively
 Anxiety and Eating Disorders in Adult Women 87
http://dx.doi.org/10.5772/65249

evaluated because of one’s appearance, fear of negative evaluation refers to the idea that one’s
social self is likely to be judged negatively [ ]. Another possible vulnerability factor shared by
both types of disorders may be intolerance to uncertainty [ ]. Fear or intolerance of uncer‐
tainty implies an impression of uncontrollability and unpredictability that has been found in
individuals with ADs, GAD especially [ ], as well as in AN and ”N patients [ ]. Individuals
with intolerance of uncertainty perceive uncertainty as stressful, upseting, and unfair [ ].
They atribute a negative meaning to uncertainty and believe it should be avoided [ ]. In
individuals with ED, this personality factor has been suggested to be linked to a need for
control, cognitive avoidance, and low novelty seeking [ ]. It is also linked to an increased
need of predictability and a disposition to avoid new situations [ ]. In those who show high
levels of intolerance of uncertainty, the ED represents an atempt to gain control over inter‐
personal and life stressors [ ]. It provides security and certainty [ ].
When focusing on the chronology of onset of ADs and EDs, one must take into account the
natural course of both disorders as well as the fact that the sequence of onset varies according
to the AD diagnosis [ ]. First, with regard to the course of these disorders, it must be considered
that AN typically develops at a younger age than ”N [ ], SAD is more likely to begin
in childhood, and GAD usually develops in adolescence or early adulthood [ ]. Therefore,
the associations found between AD and ED and their chronology of appearance may not
represent a higher risk for AD patients to develop an ED later in life but it could instead relect
the natural course of both disorders, with ADs, in most cases, appearing earlier than EDs.
Second, the sequence of onset seems to difer depending on the type of AD while SAD and
speciic phobia usually occur prior to ED, GAD has been found to occur simultaneously or
after the onset of ED [ , ]. Moreover, agoraphobia and panic disorder appear more likely to
develop after the ED [ ].

. Deepening the association between ADs and EDs

ED patients experience high levels of anxiety in a wide variety of eating situations. Among the
eating situations that elicit anxiety in over % of patients with ED, Webb et al. [ ] identiied
the following eating more than what they had planned, eating when they had not planned to,
binge eating, eating in front of others who are thinner, eating when self‐conscious of what they
are wearing, eating in new situations, eating in front of strangers, and eating in restaurants. In
the same study, the strategies used to manage anxiety by ED patients when confronted with
anxiety‐provoking eating situations were avoiding thinking of calories and fat contained in
food, eating in a particular way or in a particular order, and using distractions when eating [ ].
Findings from this study highlight a tendency to resort to safety behaviours and cognitive
avoidance strategies to manage the anxiety rising from eating situations [ , ]. They can be
understood in light of the cognitive model of anxiety disorders put forward by ”eck and
colleagues [ , ] and in which anxiety occurs when a situation is perceived as dangerous [ ].
According to this model, anxiety requires an excessive threat meaning to innocuous situations
and an underestimation of personal coping resources [ ]. Threat meaning and lack of personal
coping resources are found in ED women. They perceive eating situations as menacing, as they
88 Eating Disorders - A Paradigm of the Biopsychosocial Model of Illness

evoke strong emotional reactions such as fear and disgust. They also tend to believe they may
not have the appropriated resources for dealing with these situations and tend to avoid them.

. . Atentional bias towards threat and coping resources

In the ield of anxiety, it has been suggested that an atentional bias towards threat contributes
to the development and maintenance of ADs [ ]. In ED women, atention biases are centred
on threat stimuli relating to food, weight, and shape [ ]. A processing priority is given to fear
of weight gain as women with ED tend to focus on information that conirms rather than
invalidates this fear [ ]. According to Nelson and her colleagues [ ], state anxiety further
increases the atention bias by maintaining the atention on the threat stimuli. Consequently,
women with ED who have a comorbid AD are likely to experience state anxiety more often
than those without AD when confronted to their feared eating‐ and weigh‐related stimuli, and
such atention bias can exacerbate their anxiety and even precipitate binge eating [ , ]. Thus,
while trait anxiety is likely to predispose to and precede AD and ED onset, state anxiety would
play an active role is the maintenance of both disorders through an atentional bias towards
threat.

When encountering stressful situations, individuals with ED also tend to doubt their ability
to deal with and solve these situations [ ], which can anchor deeper the belief they must keep
fearing eating‐ and weight‐related threat stimuli. Such negative problem orientation has also
been found in individuals with ADs [ ]. In fact, negative problem orientation implies a
catastrophic appraisal of stressful situations and of their consequences [ ]. It has been related
to poor performance on problem solving and decision making [ ]. Along that line, research
shows that women with ED are more susceptible than women without ED to assess stressful
situations in a catastrophic way, perceive themselves as being under great amount of stress,
and rely on dysfunctional coping strategies such as avoidance‐oriented or emotion‐oriented
strategies [ ]. Moreover, their active and repetitive use of behaviours such as restrictions and
binge eating leads them to think this is an efective way of avoiding and geting rid of negative
afect, and particularly of anxiety. It can even negatively impact their likelihood of resorting
to active confrontive and more functional coping strategies [ ].

. . Safety behaviours

In anxious individuals, safety‐seeking behaviours are used as a means of gaining control over
feared situations, preventing a possible catastrophe, and avoiding situations leading to
worrisome thinking [ , ]. They reduce the anxiety level in the short term but maintain it in
the long term. Ritualistic and slow eating, restricting oneself to only certain foods, which are
considered safe foods, eating foods in a particular order, and body checking are examples of
safety behaviours in women with ED. Safety behaviours also include behaviours related to
body avoidance such as refusing to be weighted, avoiding mirrors, and wearing baggy clothes
[ ]. While body checking involves scrutinizing one’s body repeatedly, body avoidance implies
not wanting to learn information from the body or to see one’s body [ ]. As suggested by
Pallister and Waller [ ], these rigid behaviours are used in an atempt to get control over eating,
weight, and shape and to prevent the catastrophe of gaining weight. They provide a form of
 Anxiety and Eating Disorders in Adult Women 89
http://dx.doi.org/10.5772/65249

reassurance that unfortunately maintains the ED and, as long as they don’t try to disconirm
their fears, the anxiety is also maintained in the long term [ ]. Furthermore, when eating
restrictions are involved, safety behaviours can lead to a loss of control over eating through an
increased risk of binge eating [ ].
Safety behaviours can be related to the sense of uncontrollability and unpredictability over
certain dimensions of their environment that individuals with a comorbid AD and ED
experience [ ]. Women with ED aim to control their eating so they may not be confronted
with a perceived lack of control over the interpersonal and stressful life events they encounter
[ ]. That way, they manage an internal sense of certainty and diminish their negative
perception of being unable to handle the stressful situation [ ]. The ED therefore fulils their
need for security and certainty [ ].

. . Cognitive avoidance strategies

Cognitive avoidance strategies for their part rely on mechanisms like cognitive narrowing,
blocking, and dissociation [ ]. The anxiety literature suggests that these strategies involve a
form of worrisome thoughts substitution and suppression, which allows for diminished
unpleasant emotional arousal [ ]. They can maintain ADs by impairing the opportunity for
a given individual to learn he can handle the feeling of being anxious as well as the stressful
situation [ ]. Pallister and Waller [ ] regard cognitive narrowing as a strategy that brings the
atention towards an immediate and present stimulus and requires concrete and low‐level
thinking. While using cognitive narrowing, a person could for example try to substitute
worries by neutral or positive thoughts or use distraction. ED women who rely on cognitive
narrowing can focus on and monitor their eating, which reduces their likelihood of experi‐
encing emotional distress and anxiety. Cognitive narrowing also allows for less binge eating
in the short run. However, given the food restrictions implicated, an increased risk of binge
eating occurs later on [ ].
The cognitive avoidance strategy of blocking is used to reduce aversive self‐awareness and
emotional distress [ ]. In ED women, blocking mainly involves binge eating, which is used in
order to block or anaesthetize negative emotional states arising from stressful and painful
interpersonal situations [ ]. Instead of directing their atention on trying to resolve the situation
and diminish their emotional arousal, they focus on food. The afect regulation model [ ]
appears closely related to cognitive avoidance strategies since it posits that women with ED
overeat in response to emotional arousal or stress [ ]. Thus, as anxiety increases, disordered
eating behaviours like binge eating and vomiting may occur more frequently in order to
regulate emotions and reduce an emotional void associated with boredom or loneliness [ ,
]. Sadly, instead of alleviating the emotional distress of the women who adopt these
behaviours, they can elicit undesirable emotions like shame and reinforce body dissatisfaction,
which in turn further increase social anxiety when one has to expose her body to the scrutiny
of others [ ]. Social evaluation concerns may thereafter accentuate the need to resort to binge
eating [ ], creating a vicious circle for women with comorbid AD and ED.
Dissociation acts as another cognitive avoidance strategy since it blocks out painful emotions
and excludes information from consciousness [ ]. According to Pallister and Waller, a high
90 Eating Disorders - A Paradigm of the Biopsychosocial Model of Illness

proportion of ”N patients report some depersonalization and derealization when they binge
[ ]. In restrictive AN patients, it has also been found that those who report higher social anxiety
display higher dissociation [ , ].
In sum, eating behaviours like dieting, fasting, vomiting, and exercising excessively can be
used as ways of reducing and in some instances eliminating anxiety, albeit temporarily, in
individuals with AN, ”N, and binge‐eating disorder [ , ]. This patern of association is
highlighted in Fairburn’s transdiagnostic model of ED, in which anxiety‐triggering situations
encountered lead to a need to resort to disordered eating behaviours as a way to modulate and
reduce anxiety [ ].

. Treatment considerations

ED patients with comorbid ADs are more likely to experience persisting ED symptoms, poor
functioning, and higher psychosocial impairment and mortality risk than those without such
comorbidity [ ]. Thus, as suggested by Hughes and colleagues, comorbidity can be seen as a
marker of illness’ severity. Furthermore, through fear of negative evaluation and cognitive
avoidance, anxiety can complicate treatment or even negatively afect engagement in treat‐
ment [ ]. Such considerations highlight the need to consider and implement anxiety‐focused
interventions in the treatment of EDs. Additionally, when ADs and EDs co‐occur in a given
patient, it appears essential to opt for interventions that have the potential to address both ED
and AD [ , ]. Doing so will assure beter treatment outcomes for both disorders. However,
as indicated by Steiger and Israel [ ], ED cannot be treated with an approach that would
exclusively focus on the management of anxiety symptoms. It therefore justiies the need for
a beter understanding of what uniies ED and AD in a particular individual, as well as what
diferentiates the two in order to obtain optimal treatment efects.
The concepts of phobias and fears may be particularly relevant to use in the treatment of ED
patients in order to explain their reluctance to gain weight and their bodily concerns [ ]. As
suggested in the cognitive behavioural treatment approach, psychoeducation about the
relationships between thoughts, emotions, and behaviours could be given to ED patients with
AD [ ]. Additionally, psychoeducation about anxiety as a negative efect and the ineicacity
of disordered eating in dealing with distress in the long term should be provided to women
seeking help for ED [ ]. Relevant concepts explaining GAD, such as intolerance of uncertainty,
positive beliefs about worries, negative problem orientation, and cognitive avoidance, could
also be covered through psychoeducation.
Cognitive behavioural strategies used for managing and reducing anxiety can wisely be
applied for treating ED women who experience high anxiety levels and ADs [ ]. Table
presents some ED and AD treatment focus, as well as diferent type of interventions considered
appropriate to address these focus. Treatment of ED should involve relecting about threat‐
related cognitions [ ], developing coping skills through problem‐solving training, as well as
developing behavioural experiments aiming at softening rigid cognitive and behavioural
eating paterns [ ]. More realistic estimates and evaluations of feared eating‐ and weight‐
 Anxiety and Eating Disorders in Adult Women 91
http://dx.doi.org/10.5772/65249

related stimuli need to be developed by women with ED, and negative problem orientation
could be worked on by identifying the consequences of such negative orientation and devel‐
oping a perception of threats and problems as opportunities and normal parts of life [ ].

Treatment focus Types of intervention

Intolerance of uncertainty and • Challenging positive beliefs about worry
excessive worry
• Recognizing that certainty cannot be atained

• Identifying manifestations of intolerance of uncertainty

• In vivo exposure to uncertainty

Atentional bias towards • Relecting about threat‐related cognitions

threat and negative problem
• Discussing the emotional, cognitive, and behavioural consequences of a negative
orientation
problem orientation

• Cognitive restructuring problems and stressful situations as a normal part of life

and an opportunity rather than a threat

Coping skills • Problem‐solving training

• Mindfulness and relaxation techniques

• ”ehavioural activation and decision making

”ehavioural avoidance • Exposure to fearful situations

e.g. Ritualistic eating, body
• Mirror exposure
checking, and body avoidance
• Graded body image exposure

• Exposure plus response prevention

Cognitive avoidance e.g. • Exploring of the relationship between emotions, cognitions and behaviours
cognitive narrowing, blocking,
• Tolerance of emotional distress
and dissociation
• Emotional processing

• Imaginal exposure

Table . AD‐ and ED‐related focus of treatment and appropriate types of intervention.

Selected interventions, encompassing ADs and EDs, should focus on reducing safety behav‐
iours such as eating only certain foods perceived as less risky and fatening, eating in a
particular way, and using body checking to maintain control over weight and eating [ , ]. ”y
using behavioural experiments, ED women with a comorbid AD can test out whether or not
their fears and dysfunctional beliefs regarding the non‐use of their safety behaviours prove to
be true [ ]. As suggested by Levinson and Rodebaugh [ ], some behavioural experiments could
be centred on social appearance anxiety. For example, ED patients could be instructed to talk
about a certain aspect of their appearance with others in order to disconirm their belief that
92 Eating Disorders - A Paradigm of the Biopsychosocial Model of Illness

others mainly focus on that aspect of their physical anatomy and that they may reject them
based on their perceived physical laws [ ].

To deal with behavioural avoidance, exposure to anxiety‐provoking eating situations also

seems essential to use as an intervention strategy. As for behavioural experiments, exposure
allows for disconirming the ED patients’ fears of catastrophe and improving their beliefs
that they have the internal resources to cope with the situations they avoid. In an exposure
plus response prevention intervention strategy, patients with ED are encouraged to eat
forbidden foods exposure and to keep themselves from vomiting response prevention
[ ]. Past research has shown that body checking and body avoidance, which can be
conceptualized as behavioural manifestations of an overvaluation of weight and shape, can
be efectively addressed through exposure [ ]. In fact, interventions strategies like mirror
exposure and graded body image exposure are promising for ED women [ ]. Mirror
exposure allows for habituation to and a reduction of the distressing thoughts and feelings
experienced towards the body. It has been shown to signiicantly increase body satisfaction
and decrease of body avoidance [ ]. For its part, graded body image exposure uses
psychoeducation about body avoidance and the overvaluation of weight and shape as well
as a hierarchy of anxiety‐provoking situations that are avoided with the goal of helping
women with ED learning that their fears with regard to their weight and shape are harmful
to them and unlikely to happen [ ].

Treatment also has to consider cognitive avoidance strategies that are used to either escape
from or reduce aversive self‐awareness and negative afect [ ]. Cognitive narrowing and
blocking can be targeted by focusing on the underlying emotions and distress that ED women
are anaesthetizing through restrictive and binge eating. As suggested by Haynos and collea‐
gues [ ], treatment involves increasing the patient’s capacity to tolerate distress as well as
identifying how cognitions and emotions are associated. Considering that intolerance of
uncertainty may represent a shared vulnerability between ADs and EDs [ ], developing a
tolerance to uncertainty and unpredictability may also be relevant for treatment. While doing
so, manifestations of intolerance of uncertainty should be identiied and addressed through
exposure [ ]. Finally, interventions addressing cognitive narrowing and blocking should
investigate and test the ED patients’ beliefs about negative emotions, and particularly about
anxiety [ ].

. Conclusion

Anxiety symptoms and ADs are frequently reported in women with ED. In fact, comorbid ADs
are prevalent across the full spectrum of ED and particularly likely to be observed in clinical
inpatient and outpatient samples. Although the understanding of the nature of the link
between anxiety and ED still has to be explored and deepened, most available research
focusing on the AD‐ED comorbidity suggests that, in an high proportion of ED women,
disordered eating symptoms are preceded by symptoms of anxiety and even considered as
anxiety driven. Therefore, AD should be systematically assessed and addressed in women
 Anxiety and Eating Disorders in Adult Women 93
http://dx.doi.org/10.5772/65249

with ED. ADs play a maintaining role in the symptomatology of ED and thus must be
recognized and treated as soon as possible [ ]. Moreover, diferent mechanisms involved in
both ADs and EDs need to be considered as treatment‐appropriate focus. Among them,
intolerance of uncertainty, atentional bias towards threat, negative problem orientation, and
behavioural and cognitive avoidance appear particularly relevant.

In sum,
• Up to % of women with AN and ”N present an AD.

• GAD and SAD are the most frequently AD diagnoses in women with ED.

• Three temporal sequences of the onset of AD and ED have been suggested, with the one in
which AD precedes ED disposing of the most empirical support.

• ED and AD present a shared vulnerability through adverse childhood experiences, negative

afect, fear of negative evaluation, and intolerance of uncertainty.

• Atentional bias, coping resources, safety behaviours, and cognitive avoidance strategies
can be found in women with ED.

• Treatment for ED women with a comorbid AD should involve behavioural experiments,

exposure, problem‐solving training, and tolerance of emotional distress and uncertainty.

Author details

Annie Aimé , *, Tanya Guitard and Lise Grousseaud

*Address all correspondence to annie.aime@uqo.ca

Department of Psychoeducation and Psychology, Université du Québec en Outaouais, Saint‐

Jerome, Quebec, Canada

Clinique IMAVI, Gatineau, Quebec, Canada

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