Conceptualizing eating disorder psychopathology using an anxiety disorders framework: Evidence and implications for exposure-based clinical research
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Eating disorders (EDs) and anxiety disorders (ADs) evidence shared risk and significant comorbidity. Recent advances in understanding of anxiety-based disorders may have direct application to research and treatment efforts for EDs. The current review presents an up-to-date, behavioral conceptualization of the overlap between anxiety-based disorders and EDs. We identify ways in which anxiety presents in EDs, consider differences between EDs and ADs relevant to treatment adaptions, discuss how exposure-based strategies may be adapted for use in ED treatment, and outline directions for future mechanistic, translational, and clinical ED research from this perspective. Important research directions include: simultaneous examination of the extent to which EDs are characterized by aberrant avoidance-, reward-, and/or habit-based neurobiological and behavioral processes; improvement in understanding of how nutritional status interacts with neurobiological characteristics of EDs; incorporation of a growing knowledge of biobehavioral signatures in ED treatment planning; development of more comprehensive exposure-based treatment approaches for EDs; testing whether certain exposure interventions for AD are appropriate for EDs; and improvement in clinician self-efficacy and ability to use exposure therapy for EDs.
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Anxiety-based models suggest that the physical subdomain of anxiety sensitivity specifically is a potential mechanism linking eating disorders and anxiety disorders.
“All domains of AS may be elevated in EDs, however, anxiety-based models of EDs would suggest that it is the physical subdomain specifically that is a potential mechanism linking EDs and ADs (Schaumberg et al., 2021).”
From Early reduction in anxiety sensitivity predicts greater reduction in disordered eating and trait anxiety during treatment for bulimia nervosa. (2024) · cites this paper as Schaumberg et al., 2021
The Core symptom characteristics section describes interoceptive discomfort and fear as relevant to eating-disorder symptoms. The Interoceptive exposure section discusses sensitivity to physical sensations in eating disorders and anxiety-related conditions. These passages support a possible shared physical-sensation mechanism, but they do not identify the physical subdomain of anxiety sensitivity specifically as that mechanism (page numbers unavailable). (LLM, conf=0.82)
Experimental — accuracy not yet measuredAnxiety-based models of eating disorders propose that aversive learning experiences with body sensations lead to hypersensitivity to interoceptive cues, and that eating disorder behaviors reduce discomfort and are negatively reinforced over time.
“Anxiety-based models of EDs propose that aversive learning experiences with body sensations lead to hypersensitivity to interoceptive cues; ED behaviors reduce that discomfort and are thereby negatively reinforced over time (Schaumberg et al., 2021).”
From Early reduction in anxiety sensitivity predicts greater reduction in disordered eating and trait anxiety during treatment for bulimia nervosa. (2024) · cites this paper as Schaumberg et al., 2021
Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredAnxiety is a transdiagnostic factor involved in the development and maintenance of anorexia nervosa and is predictive for its course and treatment outcomes.
“A transdiagnostic factor that is involved in the development, maintenance of, and is predictive for the course and treatment outcomes of anorexia nervosa is anxiety [10–20].”
From Anxiety matters: a pilot lab study into food, weight, and virtual body exposure in anorexia nervosa (2024) · cites this paper as [19]
The Abstract and Core symptom characteristics sections describe anxiety and fear-related avoidance as relevant to the development and maintenance of eating disorders, including anorexia nervosa. The section on therapeutic process variables says avoidance can influence treatment success, but does not establish that anxiety predicts the course or treatment outcomes of anorexia nervosa specifically. No page numbers are provided in our copy. (LLM, conf=0.84)
Experimental — accuracy not yet measuredExposure therapy has recently been used for eating disorders to target fear and anxiety processes thought to maintain eating pathology.
“Exposure therapy has more recently been applied to the treatment of eating disorders (EDs; for a review see Butler & Heimberg, 2020) to target fear and anxiety-related processes theorized to maintain eating pathology”
From Are within- and between-session changes in distress associated with treatment outcomes? Findings from two clinical trials of exposure for eating disorders (2024) · cites this paper as Schaumberg et al., 2021
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Tomba, E., Tecuta, L., Crocetti, E., Squarcio, F., & Tomei, G. (2019) · International Journal of Eating Disorders · doi:10.1002/eat.23095 · Cited by 61 · see citing works
Extinction theory & anorexia nervosa: Deepening therapeutic mechanisms
Murray, S. B., Treanor, M., Liao, B., Loeb, K. L., Griffiths, S., & Le Grange, D. (2016) · Behaviour Research and Therapy · doi:10.1016/j.brat.2016.08.017 · Cited by 60 · see citing works
Khedr, E. M., Elfetoh, N. A., Ali, A. M., & Noamany, M. (2014) · Restorative Neurology and Neuroscience · doi:10.3233/rnn-140392 · Cited by 59 · see citing works
Summers, B. J., & Cougle, J. R. (2018) · Journal of Abnormal Psychology · doi:10.1037/abn0000387 · Cited by 59 · see citing works
Treasure, J. L., Cardi, V., & Kan, C. (2011) · European Eating Disorders Review · doi:10.1002/erv.1090 · Cited by 58 · see citing works
The pros and cons of change in individuals with eating disorders: A broader perspective
Gale, C., Holliday, J., Troop, N. A., Serpell, L., & Treasure, J. L. (2006) · International Journal of Eating Disorders · doi:10.1002/eat.20250 · Cited by 58 · see citing works
Davey, G. C. L., & Chapman, L. A. (2009) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.623 · Cited by 56 · see citing works
Anorexia nervosa trios: behavioral profiles of individuals with anorexia nervosa and their parents
Jacobs, M. J., Roesch, S., Wonderlich, S. A., Crosby, R. D., Thornton, L. M., Wilfley, D. E., Berrettini, W. H., Brandt, H., Crawford, S. F., Fichter, M. M., et al. (2008) · Psychological Medicine · doi:10.1017/s0033291708003826 · Cited by 56 · see citing works
Boswell, J. F., Anderson, L. M., Oswald, J. M., Reilly, E. E., Gorrell, S., & Anderson, D. A. (2019) · Behaviour Research and Therapy · doi:10.1016/j.brat.2019.02.004 · Cited by 56 · see citing works
Self-citationLevinson, C. A., Brosof, L. C., Kinkel‐Ram, S. S., Pruitt, A., Russell, S., & Lenze, E. J. (2019) · Eating Behaviors · doi:10.1016/j.eatbeh.2019.05.001 · Cited by 53 · see citing works
Self-citationSensory modulation disorder symptoms in anorexia nervosa and bulimia nervosa: A pilot study
Brand‐Gothelf, A., Parush, S., Eitan, Y., Admoni, S., Gur, E., & Stein, D. J. (2015) · International Journal of Eating Disorders · doi:10.1002/eat.22460 · Cited by 52 · see citing works
Flagged first, then by citations
Research works printed but not linked: 3
- Thomas JJ, & Eddy KT (2018). Cognitive-behavioral therapy for avoidant/restrictive food intake disorder: children, adolescents, and adults. Cambridge University Press.
- Waller G, Cordery H, Corstorphine E, Hinrichsen H, Lawson R, Mountford V, & Russell K (2007). Cognitive behavioral therapy for eating disorders: A comprehensive treatment guide. Cambridge University Press.
- Waller G, Turner H, Tatham M, Mountford VA, & Wade T (2019). Breif Cognitive Behavioural Therapy for Non-underweight Patientts: CBT-T for Eating Disorders. Routledge.
Cited by
Sorted by citations
Avoidance in Anorexia Nervosa: Towards a research agenda
Melles, H., Spix, M., & Jansen, A. (2021) · Physiology & Behavior · doi:10.1016/j.physbeh.2021.113478 · Cited by 37 · see citing works
Christian, C., & Levinson, C. A. (2022) · New Ideas in Psychology · doi:10.1016/j.newideapsych.2022.100964 · Cited by 33 · see citing works
Self-citationTransdiagnostic fears and avoidance behaviors in self-reported eating disorders
Melles, H., & Jansen, A. (2023) · Journal of Eating Disorders · doi:10.1186/s40337-023-00745-8 · Cited by 30 · see citing works
Barlow, I. U., Lee, E., & Saling, L. (2024) · European Eating Disorders Review · doi:10.1002/erv.3032 · Cited by 31 · see citing works
Bryant, E., Aouad, P., Hambleton, A., Touyz, S., & Maguire, S. (2022) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2022.894178 · Cited by 32 · see citing works
Butler, R. M., Crumby, E. K., Christian, C., Brosof, L. C., Vanzhula, I. A., & Levinson, C. A. (2024) · Behavior Therapy · doi:10.1016/j.beth.2023.07.008 · Cited by 17 · see citing works
Self-citationInhibitory Learning during Exposure Treatment in Anorexia Nervosa: A Practical Guide
Melles, H., Duijvis, S., & Jansen, A. (2023) · Behavioral Sciences · doi:10.3390/bs13050370 · Cited by 11 · see citing works
Imaginal Exposure for Disordered Eating Related Fears: An Initial Randomized Controlled Trial
Butler, R. M., & Heimberg, R. G. (2023) · Behavior Modification · doi:10.1177/01454455221091783 · Cited by 8 · see citing works
Velkoff, E. A., Rubino, L. G., Liu, J., Manasse, S. M., & Juarascio, A. S. (2024) · International Journal of Eating Disorders · doi:10.1002/eat.24207 · Cited by 5 · see citing works
Anxiety matters: a pilot lab study into food, weight, and virtual body exposure in anorexia nervosa
Melles, H., & Jansen, A. (2024) · Journal of Eating Disorders · doi:10.1186/s40337-024-01094-w · Cited by 5 · see citing works
Butler, R. M., Christian, C., Girard, J. M., Vanzhula, I. A., & Levinson, C. A. (2024) · Behaviour Research and Therapy · doi:10.1016/j.brat.2024.104577 · Cited by 1 · see citing works
Self-citation
- Authors
- Schaumberg, K., Reilly, E. E., Gorrell, S., Levinson, C. A., Farrell, N. R., Brown, T. A., Smith, K. M., Schaefer, L. M., Essayli, J. H., Haynos, A. F., & Anderson, L. M.
- Affiliations
- University of Wisconsin–Madison (US)
- Hofstra University (US)
- University of California, San Francisco (US)
- University of Louisville (US)
- Rogers Behavioral Health (US)
- University of California San Diego (US)
- University of Southern California (US)
- Sanford Health (US)
- Pennsylvania State University (US)
- University of Minnesota (US)
- Corresponding author
- Schaumberg, Katherine
- ORCID
- Venue
- Clinical Psychology Review
- Publisher
- Elsevier BV
- Published
- 2021-02
- Volume
- 83
- Pages
- 101952
- ISSN
- 0272-7358 (ISSN-L)
- PMC
- PMC7868093
- OpenAlex
- W3101149835
- Cited by
- 121
- References
- 253
- Citations by year
- 2026: 16 · 2025: 24 · 2024: 31 · 2023: 25 · 2022: 16 · 2021: 9
- FWCI
- 0.98
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Clinical Psychology Review (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Mental Health
- Topics
- Social Sciences › Psychology › Clinical Psychology › Eating Disorders and Behaviors
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Health Sciences › Nursing › Nutrition and Dietetics › Nutrition, Health and Food Behavior
- Keywords
- eating disorders, anxiety disorders, comorbidities, exposure therapy, avoidance, reward, habit, nutritional status, neurobiology, treatment adaptation, clinician self-efficacy
- MeSH terms
- Anxiety, Anxiety Disorders, Feeding and Eating Disorders, Humans, Implosive Therapy, Psychopathology
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