Self-Esteem and Social Anxiety in Teens with Eating Disorders

Social anxiety is defined as fear of being negatively evaluated by others while in a social setting. Some 15% of the general population have levels of social anxiety that disrupt daily functioning (Soc Psychiatry Epidemiol. 1999; 34:416), and symptoms of social anxiety tend to increase throughout adolescence (Br J Devel Psychol. 2007; 25:471).

Self-esteem is at the other end of the spectrum. This sense of contentment and self-acceptance stems from one’s appraisal of self-worth, significance, attractiveness, competence and ability to satisfy one’s aspirations (Br J Psychiatry. 1988; 153:6). Low-self esteem has been well documented as a highly prevalent and a predisposing factor in patients with eating disorders. Among teens, self-esteem relates specifically to scholastic achievement, social acceptance, athletic performance, physical appearance, job competence, romantic appeal, behavior, and close friendships. Results of one study showed that basing self-esteem on body and shape and/or relationships was related to disordered eating, but basing one’s self-esteem on scholastic achievement protected against low self-esteem and disordered eating thoughts (Int J Eat Disord. 2002; 32:344).

A Canadian study

Dr. Nicole Obeid of Children’s Hospital of Eastern Ontario Regional Eating Disorder Program, Ottawa, Ontario, Canada, and colleagues designed a study to examine social anxiety and several components of self-esteem, including social competence, physical appearance, romantic appeal, and global self-worth among 344 adolescent female eating disorders patients between 12 and 18 years of age (Eat Disord. 2013; 21:140). The authors hypothesized there would be a negative correlation between social anxiety and each domain of self-esteem, and in addition that teens with restrictive type eating disorders would have higher levels of self-esteem than would teens with other nonrestrictive eating disorders. The patients completed a battery of self-report questionnaires that examined various dimensions of eating disorder pathology and associated comorbidities.

The final group of subjects was divided into four groups, based on primary diagnostic symptoms. More than half (182 teens, or 53%) presented with restricting symptoms; nearly 29% (99) presented with binge/purge symptoms; and approximately 18% (63) had a diagnosis of purging-type anorexia nervosa (AN), binge-type AN, or AN-bulimia nervosa (BN), and eating disorders not otherwise specified (EDNOS-P, EDNOS-B, or EDNOS-BP), and about 18% (63 patients) had classic symptoms of BN.

Higher esteem seen among those with restrictive-type behavior

As they had hypothesized, the authors found that the group with restricting-type eating disorders had higher scores on perceived physical appearance and global self-worth than did both the binge-purge and BN subgroups. The authors surmise that this may occur because those with restrictive behaviors feel more attractive and report greater self-worth due to their accomplishment of thin stature and their ability to lose weight. Thus, the “thin ideal” could raise self-esteem by providing the individual reinforcement that she can achieve the unhealthy goals she sets for herself.

According to the authors, the relationship between binge-purge behaviors and level of self-esteem can best be understood in the context of shame. Patients who binge-purge and those with BN symptoms have much more shame about their bodies and behaviors than do restricting patients (Clin Psychol Psychother. 2006; 13:12). Even those who use purging as a way to successfully lose weight still may be dissatisfied because of overshadowing extreme guilt and shame. These patients also tend to have higher body mass indexes than do restricting patients, which can also contribute to greater shame and lower self-worth.

A strong negative correlation was also found between social anxiety and perceived global self-worth, consistent with results of earlier studies. No specific significant age effects emerged for any of the examined domains of self-esteem or for social anxiety levels.

There were several limitations to the study. The relationship between social anxiety and self-esteem yielded only correlations, so that the study could only illustrate the strength of the relationships, not causality. Also, while there was a large sample group, once this group was divided into subgroups, the sample size for each varied widely.

How the study’s results might be useful

Dr. Obeid and her co-workers feel that the results of their study could be used to develop and refine assessment and treatment approaches. Because high levels of social anxiety can worsen symptoms of eating disorders, prevent patients from seeking treatment, and negatively affect treatment, understanding these relationships might help refine treatment programs. Also, raising self- esteem might improve eating disorder symptoms without even directly addressing disordered eating behavior.