In support of previous research (Bulik et al., 1991
; Wonderlich-Tierney & Vander Wal, 2010
; Utschig et al., 2010
), we found that fear of negative evaluation was able to predict a composite of disordered eating over and above fear of scrutiny, fear of positive evaluation, and social interaction anxiety. Additionally, fear of negative evaluation predicted five of the seven components of disordered eating (with the exception of body dissatisfaction and bulimia). We also found that social appearance anxiety is an additional domain of social anxiety that correlates with disordered eating.
Social appearance anxiety was able to explain additional variance in the disordered eating composite (in addition to FNE) over and above the other three domains of social anxiety we tested. Social appearance anxiety, along with fear of negative evaluation, predicted a significant amount of variance in weight concern, shape concern, and eating concern. Additionally, social appearance anxiety (but not FNE) had a unique relationship with body dissatisfaction and bulimia. Previous research has found that body dissatisfaction is a major risk factor for eating disorders, especially bulimia nervosa (Attie & Brooks-Gunn, 1989
; Killen et al., 1996
; Stice & Shaw, 2002
) and that body dissatisfaction may be the prodomal stage of development of an eating disorder (Stice, Ng, Shaw, 2010
). Our results, combined with this previous research, suggest that elevated social appearance anxiety may be a risk factor for development of eating disorders (perhaps specifically bulimia nervosa)4
through increased body dissatisfaction, whereas fear of negative evaluation may be a risk factor for anorexia nervosa (in addition to bulimia nervosa).
Additionally, we found support for two models linking social appearance anxiety with disordered eating. However, we found that the best fitting model was a model of vulnerability. First, we found that social appearance anxiety and fear of negative evaluation mediated the relationship between social anxiety symptoms and disordered eating. Indeed, the variance shared between the social anxiety symptom composite and the disordered eating composite was no longer significant when social appearance anxiety and fear of negative evaluation were considered. If this model holds in longitudinal data social anxiety may cause individuals to experience anxiety over their appearance. This appearance anxiety may cause individuals to become concerned about their overall appearance, including body image, and seek out methods to avoid their anxiety through appearance change. One way that this may manifest itself is through disordered eating. Thus, it is possible that social anxiety may cause social appearance anxiety which may, in turn, cause individuals to develop disordered eating habits. However, our data is cross sectional and causality cannot be firmly established.
We also found support for an alternative model in which both social appearance anxiety and fear of negative evaluation are vulnerabilities for social anxiety and eating disorders. We suggest that fear of negative evaluation and social appearance anxiety may be vulnerabilities that lead individuals to experience either eating or social anxiety disorders (or potentially both). We emphasize the plausibility of the vulnerability model because previous research and theory has supported fear of negative evaluation as a vulnerability for social anxiety (Haikal & Hong, 2010
; Rapee & Heimberg, 1997
). In a comparison between the two models, we found that a comparable vulnerability model was more parsimonious than the mediation model by all available indices (AIC, BIC, and chi-square difference test). This result suggests that a vulnerability model should be preferred over a mediation model based on our data. Further, when the correlation between fear of negative evaluation and social appearance anxiety was removed the mediation model did not have good fit. We argue that, in a mediation model based upon cross-sectional data, it should not be necessary for these fears to be correlated. That is, if social anxiety produces both fears (and all constructs are measured at the same time point), there should not be any shared variability remaining in the fears of evaluation. However, in a vulnerability model a correlation between the vulnerabilities was irrelevant to model fit, despite the fact that a correlation would actually be plausible in this case.
Of course, additional tests with data that can support causal inference are required (e.g., longitudinal data). Additionally, in our model we found a significant path from SAA to disordered eating but not social anxiety and a significant path from FPE to social anxiety but not disordered eating. We suggest two potential explanations for this result: (a) the path from SAA to social anxiety may be small but could attain significance in larger samples with greater power or (b) it may be that SAA confers no unique vulnerability for social anxiety symptoms above and beyond fears of evaluation, whereas it does confer unique vulnerability for disordered eating above such fears. Conversely, fear of positive evaluation may confer unique vulnerability for social anxiety but not disordered eating. Future research is needed to test these explanations. Regardless of the results of such tests, we encourage future longitudinal research exploring what additional factors lead certain individuals to develop a particular type of psychopathology (i.e., eating, social anxiety, or both). It may be that social appearance anxiety and fear of negative evaluation interact with other variables (i.e., having negative experiences with body image versus social interactions) to lead to a particular type of disorder.
Of course, the current study is not without limitations. We had a modest sample size that consisted of students. Future research should test if the results found here generalize to larger samples, as well as other populations and cultures. Additionally, one of the major limitations of this study is that our data was cross sectional and causality cannot be clearly determined. Therefore, it is crucial that future longitudinal work more stringently test the directionality of the models presented here. However, we think that as a cross-sectional research was an important first step in understanding negative social evaluation fears, social anxiety, and disordered eating. An additional limitation is that we measured social anxiety with self-report alone. It might be argued that an interview measure, such as the Liebowitz Social Anxiety Scale, would have been preferable. However, available research indicates that the interview and self-report versions of the Liebowitz Social Anxiety Scale correlate very highly (Fresco et al., 2001
), suggesting that social anxiety may be as fruitfully assessed with self-report as interview measures. Nevertheless, future research should test the relationship of social anxiety accessed via a variety of modalities with facets of disordered eating, also assessed via a variety of modalities. Finally, it should be noted that we did not test whether social physique anxiety has any incremental contributions in our model. Given problems with the factor structure of the SPAS (Eklund, Mack, & Hart, 1996
; Eklund, Kelley, & Wilson, 1997
; Eklund, 1998
; Martin, Rejeski, Leary, McAuley, & Bane, 1997
; Motl, Conroy, & Horan, 2000
) and that SPA concentrates only on physique (height, weight, and muscle tone), rather than other aspects of appearance in addition to body shape (i.e., complexion and shape and size of facial features) we chose to focus on how overall social appearance anxiety
affects disordered eating. However, we encourage future research to examine how both social appearance and social physique anxiety affect eating disorder symptoms and if the two constructs show interactive effects in predicting psychopathological variables.
Nevertheless, we believe that these results have implications for the treatment of both social anxiety and eating disorders. Exposure therapy is an efficacious treatment for social anxiety disorder (Gould, Buckminster, Pollack, Otto, & Yap, 1997
; Feske & Chambless, 1995
). Development of exposure therapy that targets social appearance anxiety may decrease levels of social appearance anxiety and prevent development of eating disorders. For example, with therapist assistance, clients could talk with a confederate about a particular part of their appearance that makes them anxious (but which is judged by the clinician to be unlikely to be of concern to others). This in-session exposure would ideally be followed by in vivo exposures in which clients repeat the procedure with people in their lives. Such exposures hold the promise of demonstrating to a client that his or her appearance is unlikely to lead to rejection. Additionally, such exposures could be integrated into current efficient treatments for eating disorders (please see Wilson, 2010
Future research should explore such treatment options in addition to continued investigation of the plausible proposition that social anxiety leads to eating disorders and/or that both disorders share common vulnerabilities. We believe that the research presented here is a step towards understanding negative social evaluation fears as an important component of social anxiety and eating disorder comorbidity. Further examination of social appearance anxiety and fear of negative evaluation can help inform our understanding of the development of eating disorders and the treatment of individuals with comorbid social anxiety and eating disorders.