Anxiety and Eating Disorders: An Introduction
Fall 2005, Vol 4, Issue 4
A. David Wall, PhD, Department of Psychological Services
Edward J. Cumella, PhD, Department of Research and Education
Remuda Ranch Programs for Eating Disorders
“An anxious heart weighs down a man… Do not be anxious about anything.” (Proverbs 12:25; Philippians 4:6)
I boarded my airplane. We taxied from the terminal to the runway. We were cleared for take off. But the pilot suddenly steered the plane to the side of the runway and stopped. Before long, we taxied back to the terminal. The pilot informed the passengers that a warning light had come on in the cockpit, indicating a serious mechanical problem.
Mechanics poured over the plane. An hour later the problem was located. The problem was not the mechanical feature that the warning light was intended to monitor, but the warning light itself. The warning light had an electrical short causing it to illuminate even though the mechanical apparatus it was monitoring was functioning normally. With this reassurance, we were cleared again for take off.
This story illustrates the anxiety process. Anxiety is the warning light within us that triggers us to search for danger. Sometimes, we feel anxiety, check out our concerns, and find nothing of consequence. Our anxiety signal turns off. For example, we hear a noise in the night and become anxious. We get up and find that the cathas knocked over a bowl. We realize there is no danger; our anxiety subsides and we go back to sleep. Sometimes there is real danger. While driving, we hear a loud popping sound and experience a rush of anxiety. We scan our surroundings and notice rubber shards flying out behind our vehicle. We slowly decelerate and stop on the roadside. Our anxiety subsides—we are safe. We then call our emergency road service and have the blown-out tire replaced by a spare. Danger averted.
But some individuals—through a combination of genetic and biochemical proneness and learning—have anxiety “warning lights” that come on very quickly and/or unnecessarily. Such persons may take unneeded evasive actions that harm their quality of life. When this happens frequently, an anxiety disorder arises. In my airplane experience, the warning light came on while the plane was safely on the ground. But what if that light had suddenly illuminated as we were actually lifting off? The pilot might have become quite concerned and taken serious evasive actions. If there had been real danger, these actions would have reduced it. But the evasive actions may have also had some element of risk in them. Since they would have been triggered by a faulty warning light, the evasive actions might have put the plane in more danger than it was truly in.
Anatomy of Anxiety
Each human being is wired with a life-saving, genetically-derived, biological system called anxiety that resembles the airplane warning light. Anxiety is a feeling—a specific physiological arousal involving shakiness, perspiration, racing heart, rapid and shallow breathing. Individuals differ in their ability to tolerate anxiety. Sometimes small amounts of anxiety are experienced as stimulating and positive; e.g., some people pay good money to ride on roller coasters. But as anxiety intensifies, it is ultimately experienced as aversive.
The aversive nature of anxiety motivates us to eliminate or reduce it. Anxiety reduction involves two processes: 1) an instinctive response of retreat or escape–“let me out of here”; and 2) a drive to determine the source of the anxiety and danger level. If immediate escape is unsuccessful in reducing anxiety or not possible, motivation to find the source intensifies.
Let’s use an analogy. Imagine you feel pain in the center of your chest. If the pain is barely perceptible, you may ignore it. If more intense, you are likely to ask, “What is that?” If it soon goes away, you may give up searching for its cause and move on. If it remains, you will likely continue focusing on it, seeking its meaning. Similarly, the noxious experience of anxiety causes us to become hypervigilant when it intensifies and/or persists.
Trying to find the source of anxiety is a cognitive or thinking process. Our search for the cause of anxiety is not random, but directed by clues from our current environment and learning history, such as what we have come to believe is dangerous. Sometimes the source of our anxiety is immediately apparent—e.g., being robbed. At other times, we are unsure and the process prolongs.
When we begin to focus on a specific source of our anxiety, we are using a mental process called attribution. We see a snake; we attribute danger to the snake’s presence and take action based on this attribution. This example makes common sense, because our anxiety correctly led us to assess the environment for danger, the danger was real, and our fleeing response reduced the danger.
Fear is the emotion that results when we causally attribute the noxious feeling of anxiety to a particular situation. We come to fear that situation. Our fear level is directly correlated with the perceived danger of the situation. A situation’s dangerousness is always related to our belief in its power to take away something we value. Fear level increases proportionate to how much we value what we may lose.
Always is a strong word, but applies in this case. If I fear physical attack by an animal, the fear is based on my belief that the animal has the power to take away something I value—my physical well-being. So I avoid that animal. If, on the other hand, that animal is a threat to my daughter, I may approach and neutralize the animal because I value my daughter’s welfare more than I value my own. Hence, the fear of one event can override the fear of another. With one question, it becomes clear that fear level is always directly correlated with the value we place on what we might lose. Which creates more fear for a parent: a stolen car or a kidnapped child? The difference derives from the value we place on the child versus the car.
From Functional Process to Disorder
Problems can arise with the genetic/biological basis of anxiety and the cognitive attribution process by which we determine what in the environment is causing our anxiety. Both classical and operant conditioning also play a role in the development of anxiety disorders.
First, genetics renders individuals more or less vulnerable to anxiety problems. Some people are born “high strung” and have anxiety warning lights that turn on with less or little provocation. Anxiety proneness is not dichotomous, but falls on a continuum. In addition to psychotherapeutic interventions, individuals who are genetically prone to anxiety may benefit from non-addictive medications that partially correct this biochemical proneness, such as selective serotonin reuptake inhibitors; or, for short term relief during acute anxiety states, from anxiolytic medications such as benzodiazepines.
Second, growing up in dangerous situations renders certain people more prone to anxiety problems. When children grow up in stressful environments that are physically and/or emotionally dangerous, their brains’ anxiety warning lights come on frequently and accurately. Over time, constant arousal and need for vigilance creates an anxiety response with a hair trigger. When such persons are adults and move into safe and stable environments, the sensitivity to danger that they needed to develop during childhood leaves them with near-constant anxiety. Much like individuals with genetically-based anxiety proneness, these individuals likely have a neuro-chemical tendency to experience anxiety, and may benefit from pharmacological interventions in addition to psychotherapy.
Third, anxiety problems can arise based on modeling. Even children who grow up in stable environments learn to define danger by watching how their parents react to various situations. If parents react with great fear to relatively benign situations, children also learn to attribute danger to, and thus to fear, those situations.
Fourth, classical conditioning can create anxiety problems. Our brains not only look for dangerous situations, but also for cues suggesting that danger is present or immanent. When we encounter danger, our brains remember the situation as well as the events leading up to it, even if we cannot consciously recall these events. Reacting to the lead-up events or cues is a basic survival issue. It increases the speed with which we can detect danger, making it more likely that we will escape unharmed. This process is largely the result of classical conditioning. Classical conditioning occurs when a cue that is not normally capable of triggering a specific response develops the capacity to trigger that response. This happens when a neutral cue is paired in time with a cue that is capable of triggering the specific response. For example, if a young child lives in a family where the mother and father fight every night at dinner, food—which normally does not trigger anxiety—can become a cue that triggers anxiety in the child, because it is paired in time with the parents’ arguments—something that naturally triggers the child’s anxiety.
Fifth, operant conditioning can reinforce anxiety problems. When we repeatedly avoid situations that we believe to be dangerous, the avoidance behavior reduces our anxiety about those situations. Our actions of avoiding are reinforced and strengthened because they reduce our anxiety. The process by which a behavior is strengthened because it reduces anxiety is called negative reinforcement. Situations that we repeatedly avoid will continuously be perceived by us as dangerous, because we will not have an opportunity to challenge that perception by entering into the situation and experiencing it differently.
For a more detailed cognitive-behavioral understanding of anxiety, anxiety disorders, and the treatment thereof, see Barlow (2004) or Beck, Emery, & Greenberg (1990).
Developing a Specific Anxiety Disorder
One patient with obsessive-compulsive disorder used the word “spinning” to describe her horribly distressing mental condition. One imagines a front-loading clothes dryer spinning endlessly around and around. This spinning process is largely inherited—a genetic and neurobiological proneness to anxiety—although environment may play a role. The spinning is the alarm going off—constant anxiety about something, leading to worry and rumination in an effort to understand the source of the anxiety.
Clothes dryers usually have something in them as they spin around and around. Contents may differ from dryer to dryer and over time. Dryers may be filled with socks, shirts, pants, or combinations of clothes. The contents of the “spinning” anxiety process can change from one person to another, and may also change for one individual over time. In short, the anxiety is a constant; the object of the anxiety may shift.
Let us look at this developmentally. A young child is genetically anxiety-prone. She experiences the noxious feeling of anxiety. Anxiety pushes individuals to seek a causal object. The attribution the child ultimately makes about the content or target of her anxiety will be developmentally appropriate. A child at an early age is not likely to be overly concerned about peers, finances, or grades, but may be concerned about the developmentally appropriate fear of losing a parent. Her anxiety may therefore manifest as separation anxiety disorder. Later, as the child grows and begins to understand death, she may fear illness and develop a related germ phobia. Later still, in adolescence, peer acceptance becomes extremely important, so now she worries about whether she is overweight.
Research suggests that anxiety disorders often precede eating disorders (Bulik, Sullivan, Fear, & Joyce, 1997; Godart, Flament, Lecrubier, & Jeammet, 2000; Yaryura-Tobias et al., 2000). In many ways, eating disorders can be understood as anxiety disorders with specific food and weight-related content. In fact, at Remuda we often see patients who had obsessive-compulsive disorder prior to their eating disorder. Their earlier obsession with germs was replaced by an obsession with calories. Their earlier compulsion to wash was replaced by a compulsion to purge. Is this a normal developmental route for a single anxiety process? Is there really only one disorder present with different contents? For some patients, this is a possibility.
Some Remuda patients were once obese. Obesity in our society can be socially dangerous, especially for children. Some patients have been actively teased to the point of being emotionally tortured; some have been rejected and ignored. Either way, obesity created trauma—a hypervigilant, ever-present anxiety. Anxiety pushes for escape behaviors. An obsess girl may have tried many things, but nothing worked until she developed an eating disorder. She lost much weight and the teasing and rejection have ended. Patients with post-traumatic anxiety experience fear in response to any cue that reminds them of their trauma. They go to extremes to avoid these cues. For someone who has experienced emotional trauma due to obesity, the cues are food and weight gain. Fear always involves losing something of value. Such patients value not being emotionally tortured and socially rejected. They attribute their pain to obesity. Asking such patients to give up an eating disorder is asking them to risk a return to the past when life was filled with emotional pain.
Family and cultural differences also influence the attribution/content selected by each individual. In the US, women are more vulnerable to eating disorders, in part because they model their concerns and behaviors after mothers and female friends who are weight-obsessed and they are told “you can never be thin enough”. Seldom will you hear that phrase spoken to a man. Men and women may both have spinning dryers—anxiety prone brains—but the content may be very different because of cultural influences.
Although people sometimes perceive body image issues in eating disorder patients as indicating a desire to look like a super-model, this is often not the case. Some patients do not want to be sexually attractive; they may, in fact, want just the opposite. We often see adolescents from Christian families. These adolescents have heard about other girls having sex and are very aware of girls who flaunt their sexuality. They are taught that this is wrong and they may have learned from their parents to fear sexuality as dangerous. As they begin to mature physically, peers may tease and boys may make sexually charged comments. Although parents may attempt to be supportive and inform adolescents that their development is normal, it is difficult for them to understand how something can be good and bad at the same time. Such adolescents may attribute their anxiety to their sexual development. Their natural instinct is to avoid the source of their anxiety. How do you avoid physical development? Anorexia nervosa stops—and may even reverse—physical development in teens. It offers an escape that removes individuals from peer pressures and from their own guilt about sexual development, which they may view as bad or dirty.
Over the years we have also observed many patients who can be described as having “impulse phobia”. These individuals have developed intense fear of their own impulses. If they date, they fear losing control and engaging in unwanted sexual activities. If they get angry, they fear losing control and hurting someone emotionally. If they eat, they fear they will not stop and will become obese. If they express feelings directly, they fear being unable to contain themselves. Fear always involves losing something of value. These individuals value what they define as “being good” and “feeling in control”, as well as family approval for these attributes. There are particular psychological, familial, and cultural reasons why they have come to value these attributes. They know that emotions and impulses, if given enough reign, can overwhelm and rob them of what they value.
Co-Occurrence of Anxiety and Eating Disorders
There is evident overlap between anxiety and eating disorders. A recent study found 64% of eating disorder patients having one or more co-occurring lifetime anxiety disorders (Kay, Bulik, Thornton, Barbarich, & Masters, 2004). Among Remuda’s 6753 inpatients, point-prevalent percentages with an anxiety-related disorder are nearly identical—64%. Furthermore, 61% of Remuda’s inpatients evidence significant anxiety on the MMPI-2 or MMPI-A (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989; Butcher et al, 1992), and 85% evidence significant anxiety on the Beck Anxiety Inventory (Beck & Steer, 1993). See Table 1.
Anxiety issues are clearly far more prevalent among eating disorder patients than non-patients. Research also suggests that at least certain anxiety disorders are also significantly more common among eating disorder patients compared to other psychiatric patients (Grilo, Levy, Becker, Edell, & McGlashan, 1996; Kay, Bulik, Thornton, Barbarich, & Masters, 2004). The relationship between anxiety and eating disorders may indeed be more than mere co-occurrence, implying common underlying etiological mechanisms—genetic (Silberg & Bulik, in press), neurobiological, and psychosocial. It is not surprising that the range of treatments with evidence-based efficacy for anxiety—primarily cognitive-behavioral interventions such as cognitive restructuring, systematic desensitization, and exposure with response prevention—have been found effective in treating certain eating disorder symptoms as well (American Psychiatric Association, 2000).
Table 1.
Co-Occurring Anxiety-Related Disorders and Measures for Remuda’s Patients
Children (Ages 9-12) Adolescents (Ages 13-17) Adults (Ages 18-69) All Patients
N 100 1841 4812 6753
Diagnosis:
Post Traumatic Stress Disorder 2% 12% 23% 20%
Obsessive-Compulsive Disorder 25% 19% 18% 18%
Generalized Anxiety Disorder 11% 16% 18% 17%
Social Anxiety Disorder (Social Phobia) 6% 6% 5% 5%
Anxiety Disorder Not Otherwise Specified 42% 31% 25% 27%
Avoidant Personality Disorder 2% 6% 11% 10%
At Least One Anxiety Disorder 68% 62% 64% 64%
Measure:
MMPI Pt Scale indicates anxiety N/A 26% 75% 61%
Beck Anxiety Scale indicates anxiety N/A 78% 88% 85%
Anxiety’s Spiritual Dimension
Remuda uses a bio-psycho-social-spiritual model to understand and treat eating disorders and other illnesses. We have already reviewed the biological bases of anxiety disorders as a malfunction in the natural warning system that protects against danger; the psychological bases in learning theory; and the social bases in family, relationship, and cultural influences. Anxiety disorders also have a spiritual dimension.
The most common commandment in the Bible, appearing 365 times, is “fear not,” or some variant thereof. This is likely so common in Scripture, because God understands our propensity towards fear and wants to emphasize its danger and ultimate emptiness.
Fear can have great control over us. At Remuda, we see women who would literally starve to death due to fear of weight gain. People panicking in a fire may trample each other to death. Fear arises from the potential of losing something we value. When we fear loss of money, possessions, status, or power, our values and priorities are not in harmony with God’s. When we cease to value those things, we have no fear of losing them.
We are told in Scripture to fear one thing only—God himself. “The fear of the Lord is the beginning of wisdom” (Proverbs 9:10). To those of us who recognize God as the source of all love, this call to fear God can be hard to comprehend. Why would we fear an all-loving and grace-giving God? Because fear is directly related to the potential of losing something we value–the greater the value, the greater the fear. Fear of God is therefore recognition of his value. This is a protective fear. Without God, we have lost everything. As Christ so aptly puts it: “What good is it for a man to gain the whole world, yet forfeit his soul?” (Mark 8:36-37). Fear of God places everything into perspective. Nothing that we physically possess or that happens to us in this world is of any lasting consequence, so it is not spiritually healthy to fear the loss of such things. Ultimately, we will lose them all anyway at the time of physical death. "Do not store up for yourselves treasures on earth, where moth and rust destroy, and where thieves break in and steal. But store up for yourselves treasures in heaven, where moth and rust do not destroy, and where thieves do not break in and steal” (Matthew 6:19-21).
Given fear’s ability to control our lives, it is better to fear God than anything in this world. But the Bible does not stop with the idea of fearing God. As we spiritually mature, there is another step. We are told that “perfect love drives out fear” (1 John 4:18). No one will ever explain the seemingly paradoxical concept of fearing God and having love cast out fear more eloquently than John Newton in his hymn, Amazing Grace: “’Twas grace that taught my heart to fear and grace my fears relieved.”
Thus, the command, “fear not!”, is not issued as a harsh rule where failure is met with rebuke, but rather a message of hope. “The fear of the Lord is the beginning of wisdom” (Proverbs 9:10, emphasis added), for it leads us to value God above all else and to grow to the point where the world and its passing attractions cease to have unneeded value and sway in our lives. We may enjoy the world’s offerings, but learn not to attach too deeply to what is inherently transient. Simultaneously, in our relationship with God we can grow to the point where we understand God’s love for us so deeply that we are fully attached to him—valuing him above all else—because we adore him more than anything; and, where we so trust God and his plans, that our fear of life’s vicissitudes has been slowly replaced with peace. Such “perfect love drives out fear” (1 John 4:18).
For those with anxiety disorders and anxiety-related eating disorders, the process of spiritual renewal starts slowly. Distorted attributions about feared objects are challenged; the fear itself is extinguished by preventing avoidance and its negative reinforcement through a process called exposure with response prevention. Eventually, deeper spiritual truths are grasped through ongoing relationship with God, replacing belief systems that lead to unneeded anxieties about worldly losses. An example of this multi-modal approach can be found in a companion article in this issue of The Remuda Review, Banana therapy: Case study of anorexia nervosa and obsessive-compulsive disorder.
References
American Psychiatric Association (2000). Practice guideline for the treatment of patients with eating disorders (revision). American Journal of Psychiatry, Suppl., 157, 1-39.
Barlow, D.H. (2004). Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd Ed.). New York: The Guilford Press.
Beck, A.T., Emery, G., Greenberg, R.L. (1990). Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books.
Beck A.T. & Steer, R.A. (1993). Beck Anxiety Inventory Manual. San Antonio: The Psychological Corporation.
Bulik, C.M., Sullivan, P.F., Fear, J.L., & Joyce, P.R. (1997). Eating disorders and antecedent anxiety disorders: A controlled study. Acta Psychiatrica Scandinavica, 96, 101-107.
Butcher, J.N., Dahlstrom, W.G., Graham, J.R., Tellegen, A., & Kaemmer, B. (1989). Minnesota Multiphasic Personality Inventory-2: Manual for Administration and Scoring. Minneapolis: University of Minnesota Press.
Butcher, J.N., Williams, C.L., Graham, J.R., Archer, R.P., Tellegen, A., Ben-Porath, Y.S., & Kaemmer, B. (1992). Minnesota Multiphasic Personality Inventory-Adolescent: Manual for Administration, Scoring, and Interpretation. Minneapolis: University of Minnesota Press.
Godart, N.T., Flament, M.F., Lecrubier, Y., & Jeammet, P. (2000). Anxiety disorders in anorexia and bulimia: Co-morbidity and chronology of appearance. European Psychiatry, 15, 38-45.
Grilo, C.M., Levy, K.N., Becker, D.F., Edell, W.S., & McGlashan, TH. (1996). Comorbidity of DSM-III-R axis I and II disorders among female inpatients with eating disorders. Psychiatric Services, 47, 426-9.
Kay, W.H., Bulik, C.M., Thornton, L., Barbarich, N., & Masters, K. (2004). Comorbidity of anxiety disorders with anorexia and bulimia nervosa. American Journal of Psychiatry, 161, 2215-2221.
Silberg, J. & Bulik, C. (in press). Developmental association between eating disorders and symptoms of depression and anxiety in juvenile twin girls. Journal of Child Psychology and Psychiatry.
Yaryura-Tobias, J.A., Grunes, M.S., Todaro, J., McKay, D., Neziroglu, F.A., & Stockman, R. (2000). Nosological insertion of axis I disorders in the etiology of obsessive-compulsive disorder. Great Neck, NY: Institute for Biobehavioral Therapy and Research.
