Fear and Guilt in Anorexia Nervosa

fear and guilt in anorexia eating disorder

For those struggling with the eating disorder Anorexia Nervosa, guilt and fear often make it hard to break restriction behavior. Learn more about how these emotions play a major role in the cycle of Anorexia.

by: Kristin Burmeister

Restricting caloric consumption for those with anorexia is maintained partially through reinforcement. Reinforcements encourage behaviors by adding enjoyable stimuli or taking away adverse stimuli. Restriction patterns in anorexia are primarily encouraged through reinforcements related to emotions [1]. Fear and guilt, especially during meals, often reinforce the symptoms of anorexia since restriction is commonly seen as a way to decrease or avoid feelings of guilt and/or fear for those with anorexia.

One of the most common emotions associated with anorexia during meals is fear. Studies have found that anorexic individuals have higher levels of fear and anxiety around food and while eating than control groups, as would be expected [2]. Feelings of fear around food can be one of the many reasons individuals with anorexia avoid eating. Generally, more fear preceding a meal is correlated with less caloric intake and more fear following a meal is positively correlated with later restriction [3]. Furthermore, avoidance of stimuli an individual fears tends to causes fear to increase. For anorexia, fear of food and avoidance of food creates a cycle in which avoiding food creates more fear around food later which causes greater avoidance. This cycle leads to the worsening of symptoms of anorexia and causes individuals be increasingly focused on avoiding food. Thus, avoiding feelings of fear can be one of the many roots of the symptoms of anorexia.

Additionally, guilt is often a major emotion that maintains the symptoms of anorexia. Several studies have found that anorexic individuals feel more guilt surrounding their eating behaviors than control groups [4]. Feeling guilty about eating a normal meal can create a greater inclination to restrict intake and can cause food to be perceived in a more negative way [5]. Furthermore, guilt about eating can strongly predict an individual’s level of restriction and other anorexic symptoms [4]. In addition to research findings the influence of guilt in anorexia is also reinforced by first person accounts of anorexia such in memoirs and blogs. Many of these accounts discuss how guilt associated with eating often leads individuals to restrict their food intake in order to avoid guilty feelings. Thus, guilt is an additional emotion that can be a root of anorexia symptoms.

Reducing the emotional reinforcements associated with anorexia symptoms is an important aspect of the treatment of anorexia. Exposure therapy is common method used to reduce fear reactions in phobias in which individuals are exposed to the stimuli they fear. Over time exposure causes fear reactions to decrease. The application of exposure therapy in anorexia treatment uses exposure to eating foods, especially those the individual fears the most, to decrease the amount of fear those with Anorexia have surrounding food and eating [6]. Furthermore, research has found that exposure therapy leads to reduced fear before meals and an increase in consumption during a meal [6]. However, exposure therapy does not address the feeling of guilt related to eating. Therefore, other forms of treatment, such as talk therapy, are needed to address other emotions individuals with anorexia feel related to eating and food. Addressing emotions in treatment is vital because negative emotions surrounding food that remain after treatment, such as guilt, may contribute to relapses. Overall, understand the emotions that influence anorexia symptoms are important in implementing effective treatment.

[1] Haynos et al. (2017). Trajectories of higher- and lower-order dimensions of negative and positive affect relative to restrictive eating in anorexia nervosa. Journal of Abnormal Psychology, 126(5), 495-505. doi:10.1037/abn0000202

[2] Levinson, C. A., & Byrne, M. (2014). The fear of food measure: A novel measure for use in exposure therapy for eating disorders. International Journal of Eating Disorders, 48(3), 271-283. doi:10.1002/eat.22344

[3] Fitzsimmons-Craft et al. (2015). Restrictive eating in anorexia nervosa: Examining maintenance and consequences in the natural environment. International Journal of Eating Disorders, 48(7), 923-931. doi:10.1002/eat.22439

[4] Burney, J., & Irwin, H. J. (2000). Shame and guilt in women with eating-disorder symptomatology. Journal of Clinical Psychology, 56(1), 51-61. doi:10.1002/(sici)1097-4679(200001)56:1<51::aid-jclp5>3.0.co;2-w

[5] Steenhuis, I. (2009). Guilty or not? Feelings of guilt about food among college women. Appetite, 52(2), 531-534. doi:10.1016/j.appet.2008.12.004

[6] Steinglass, J., Albano, A., Simpson, H., Carpenter, K., Schebendach, J., & Attia, E. (2012). Fear of Food as a Treatment Target: Exposure and Response Prevention for Anorexia Nervosa in an Open Series. International Journal of Eating Disorders , 45(4). doi:10.1002/eat.20936    

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This post was written by BALANCE blog intern Kristin Burmeister.

Kristin is a graduate student studying social work at Case Western Reserve Universtiy. Her own recovery journey inspired her to want to help others who struggle with eating disorders. In the future, she hopes to work as a clinical social worker with a focus on eating disorder treatment.