The Connection Between Anxiety and Eating Disorders

by Amelia Davis, MD, Rosewood Medical Director

Anxiety and stress are something we all experience.  This is normal and beneficial when we are in a stressful situation, such as taking a test or when we need to meet a deadline. However, sometimes, feelings of restlessness or anxious feelings became unmanageable where excessive worry will take over one’s ability to lead a normal life, causing significant distress, affecting relationships, and even affecting one’s ability to do well in school or hold a job.  About half of individuals with eating disorders also have an anxiety disorder and most of the time, the anxiety disorder began prior to the eating disorder.  Specifically, about 72% of individuals with avoidant/restrictive food intake disorder (ARFID), have an anxiety disorder.  And not just the normal stress we all may experience, but rather extreme anxiety that limits one’s ability to function.  It is important to address comorbid (occurring at the same time) anxiety disorders in order to succeed in the treatment of eating disorders.

TYPES OF ANXIETY

The anxiety disorders that are most frequently associated with eating disorders are obsessive compulsive disorder (OCD), social anxiety disorder (SAD), generalized anxiety disorder (GAD), and post-traumatic stress disorder (PTSD).

Obsessive compulsive disorder (OCD):  Over 25% of individuals with anorexia nervosa also have OCD.  OCD is characterized as having many obsessive thoughts and compulsive behaviors such as germaphobia (fear of germs possibly leading one to wash one’s hands compulsively), obsessively counting or doing things a certain number of times, and/or doing rituals where one becomes very anxious if they don’t do in a very particular way.  Often, individuals with anorexia nervosa have similar clinical features to OCD such as rigid diet programs, obsessive thoughts relating to food, repeated weight measurements, and obsessions with calorie calculations.  They may also exhibit ritualistic behaviors related to their diets, exercises and weighing themselves.  Individuals with OCD may benefit from treatments such as cognitive behavioral therapy (CBT) and FDA approved medications such as selective serotonin reuptake inhibitors (SSRIs) (fluoxetine, fluvoxamine, and sertraline) and older medications, though may have more side effects such as tricyclic antidepressants (TCAs) (clomipramine).   Transcranial magnetic stimulation (TMS) is another non-invasive outpatient treatment that is FDA approved for treatment of OCD.  Therefore, it’s important that providers working with individuals with eating disorders recognize OCD and offer treatment for OCD as part of treating the eating disorder.

Social anxiety disorder (SAD): About 34% of individuals with anorexia nervosa experience social anxiety disorder and many more experience subclinical symptoms.  Often battling fears of judgement and public embarrassment, individuals with SAD have difficulty meeting new people and speaking in front of groups of people due to severe anxiety.  This can affect treatment as persons with social anxiety disorder are less likely to enter outpatient eating disorder treatment after an initial intake appointment.  Fortunately, treatment is available including cognitive behavioral therapy (CBT) and medications such as SSRIs (sertraline, fluvoxamine, paroxetine) and serotonin-norepinephrine reuptake inhibitors (SNRIs) (venlafaxine, duloxetine).

Generalized anxiety (GAD): Between 24 and 31% of individuals with anorexia nervosa and bulimia nervosa have GAD and about 8% of individuals with binge eating disorder have GAD.  Individuals with GAD often experience severe feelings of fear and unease and report feeling restless and irritability that interfere with the quality of their life.  They tend to worry about the same things normal people do, except that they worry much more and are unable to deal with or solve their problems effectively.  Treatment includes psychodynamic therapy, cognitive behavioral therapy (CBT) and medications such as SSRIs (escitalopram, sertraline, citalopram, paroxetine), SNRIs, (venlafaxine, duloxetine), and buspirone (azapirone and piperazine class).

Post-traumatic stress disorder (PTSD):  Studies show that the rate of PTSD in individuals with eating disorders is about 25%.  Individuals with PTSD have flashbacks and/or nightmares relating to past trauma that are very distressing as well as heightened anxiety.  It is believed that trauma, especially childhood sexual trauma, is a risk factor for the development of eating disorders.  One study showed that the diagnosis of PTSD increases the severity of the eating disorder and that the symptoms of the eating disorder start within one year following the trauma.  Treatment of PTSD includes psychodynamic therapy, cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), and medication management with SSRIs (sertraline and paroxetine).

CONNECTION WITH EATING DISORDERS

Recognizing and treating co-occurring (happening at the same time) anxiety disorders is so important in the treatment of someone with an eating disorder.  Often the two can be connected.  On the one hand, it is understandable that an eating disorder can lead to anxiety about fear of self-image, gaining weight, and societal pressures.  However, often it is the anxiety disorder that triggers and/or perpetuates the eating disorder.  With anxiety, one may feel out of control, leading to an individual to turn towards eating and food rituals to try to feel in control over their life.  Eating is the one area in our life one can exercise complete control.  And behaviors such as restricting, binge eating and purging (either from self-induced vomiting, exercise, or taking pills such as laxatives) are described as eliciting a rush or a high or a relaxing/numbing sensation and may be a way of regulating emotional distress.  While the person feels they are regaining a sense of control and lowering their anxiety, they may be making unhealthy nutrition and dangerous decisions that can have devastating long-term consequences

SEEKING HELP

Seeking help for anxiety and eating disorders is the best possible solution to help individuals achieve long-term recovery.  Prognosis is improved when people seek professional treatment early.  If you or someone you know has an eating disorder, please seek care with an eating disorder specialist as long-term recovery is possible and treatment providers can help one overcome both an eating disorder and anxiety.

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