My battle with anorexia began in as I was about to turn My husband Graham, 52, and I owned a haulage company and we had decided to run the business from our home in Blofield, Norfolk. Having work and home life so entwined took its toll. I never had any privacy except in the bathroom.
I felt suffocated. I also had problems with abusive neighbours so even when I left the house I felt under siege. We were under pressure financially and I was constantly on the phone chasing up customers who owed us money. I was juggling all this while raising three children — Barbie, now 22, Alan, 20, and Neil, So I dyed my hair and decided to lose weight. I weighed only eight-and-a-half stone at the time but I felt that a diet was part of creating a new look, a new me.
I had never dieted before but I discovered it was easy for me and that was empowering.
Now I had finally found something I could do. I felt in control. However, a few months down the track something changed. I was no longer in control; the eating disorder was in control of me. If I ate something I enjoyed, I was convinced there would be terrible consequences, that something dreadful would happen.
When I looked in the mirror, despite being very thin, I saw a fat person looking back at me. That was the beginning of my downhill slide. Anorexia had a huge and devastating effect on my relationship with my husband. He would try to get me to eat but food was the enemy so he became the enemy, too. I would say terrible things to him, threatening to end our marriage if he tried to make me eat. With my skewed logic, I believed if I was fat, people would push me about.
No matter what I said, Graham would always try to make me feel better. When he put his hands on me I thought he was trying to feel how fat I was. We still had sex, as long as it was in the dark. It was my daughter, then aged 18, who gave me the wake-up call I so badly needed. I was at my rock-bottom weight of five-and-a-half stone.
As I was scraping another uneaten meal of tomatoes and mushrooms into the bin, I turned around to find her watching me. There were other things that were frightening me into doing something about my eating disorder. The BFNE includes 12 items and measures fear of being negatively evaluated by others. It is a shorter version of the original Fear of Negative Evaluation questionnaire The removal of the four reversed scored items has been found to improve the validity of this scale 39 and therefore these items were removed from the analysis in this study.
It consists of 15 items rated on a 7-point Likert scale and participants are requested to identify how true each items feels to them.
The TB includes nine items and the PB subscale includes six items. Higher scores on each subscale indicate higher levels of perceived TB and burdensomeness.
The validation study revealed that both of these constructs had convergent associations with interpersonal constructs, such as loneliness, social support and social worth, and were associated with suicidal ideation The WSAS is a 5-item self-report scale designed to measure the degree of functional impairment. All items are rated on a 9-point Likert-type scale, ranging from 0 no impairment to 8 very severe impairment.
The maximum total score is 40, with higher scores representing greater impairment. Relationships between each of the studied variables i.
The data analysis was undertaken manually and by using the qualitative data analysis software NVivo version GA and VC familiarised themselves with the data through repeated readings, identified the initial codes i. Themes were then revised for coherence and distinctiveness and were defined and named Most of the patients were employed Half were single Forty patients reported binge and purging episodes over the previous 4 weeks.
Clinically significant levels of eating disorder symptoms 44 — 46 , functional impairment WSAS mean scores between 10 and 20 and fear of negative evaluation BFNE mean scores above 25 were found. High levels of PB i. Table 1 displays means and SDs for the demographic, clinical and social functioning measures.
Correlation analyses show significant associations between the studied variables.
Table 2. Figure 1.
Ninety participants replied to three open questions. The second question related to their current social situation and how their eating disorder impacted on their social life. Eighty-one participants reported that the eating disorder had had a negative impact on their social life. Only eight subjects reported that the eating disorder did not cause any change to their social relationships Table 3.
Sixty-three participants responded that yes, they thought that early social difficulties might have played a role in the development of the illness, four people replied that they were not sure, and 23 reported that they could not see a link between their early social life and the eating disorder Table 3. Table 3 presents the overview of the themes that emerged in relation to each question. Table 3. Main themes emerging in response to three open questions to investigate the quality of interpersonal relationships before and after illness onset, and the potential role that early social difficulties played in the development of the illness.
The aim of this paper was to test the hypotheses that: i fear of negative evaluation i. The findings corroborate the first two hypotheses, in that involuntary submissiveness and fear of negative evaluation predicted eating disorder symptoms and these associations were partially mediated by perceived lack of social competence. The findings of this study add weight to the hypotheses that suggest that social difficulties are important in the maintenance of the eating disorder [e. Importantly, these findings also demonstrate that social difficulties precede the onset of the disorder in a subgroup of patients.
This is particularly relevant considering the paucity of studies investigating the chronology of the occurrence of social difficulties in AN The identification of subgroups of individuals for whom social difficulties play a role in the onset of the disorder might inform the development of treatments that have greater specificity and relevance.
Psychiatry Trace, S. Macaluso, E. Contrary to our hypothesis and other studies suggesting that RAN have an elevated response during anticipation in the anterior insula 2 , 10 , we detected lower response during anticipation in RAN relative to CW that was localized to the ventral mid-insula. Int J Eat Disord —9. Biased interpretation of ambiguous social scenarios in anorexia nervosa.
This study provides the first evidence that submissiveness and fear of negative evaluation in particular might be causally involved in the development of the eating disorder psychopathology. Compared to the general population, people with a lifetime diagnosis of AN have recalled memories of submissiveness within the family to a greater extent than the general population 36 , It also extends the literature that have found relationships between fear of negative evaluation and abnormal eating attitudes in non-clinical samples [e.
Evolutionary theories of the eating disorder psychopathology suggest that dietary restriction and weight loss could be described as responses to the threat of social exclusion, by attempting to become more vulnerable and attractive [e. Finally, this study indicates that PB mediates the relation between involuntary submissiveness and fear of negative evaluation, and eating disorder symptoms.
The main limitation of this study is its cross-sectional design. This means that findings should be interpreted cautiously and replicated using more appropriate experimental designs. The answers to the ELES and the open questions are based on retrospective recall of early experiences and might be subject to memory biases.
The hypothesis that memories of adverse early experiences could be amplified or overrepresented in people experiencing current psychopathological symptoms is partially supported in patients with social anxiety [for review, see Ref. However, there is some indication that patients with AN tend to recall fewer and more general vs. Taken together, these findings do not seem to suggest that negative interpersonal memories are easily biased in patients with eating disorders. Only patients with a lifetime diagnosis of AN were included in this study, which does limit the conclusions that can be extended to other eating disorder diagnostic subgroups.
The qualitative analyses were based on answers to open questions, rather than semi-structured interviews that would have allowed follow-up questions and more flexibility. Despite the limitations outlined above, this study identifies potentially modifiable predisposing and maintaining factors of AN that could be targeted in treatment.
Three specific factors might be implicated in the onset and maintenance of AN: fear of negative evaluation, perceived lack of social competence and early experiences of submissiveness. A number of treatments have now been adapted or developed to target interpersonal difficulties in eating disorders e. The cross-sectional design of the study means that findings should be interpreted cautiously and replicated using a longitudinal design.
VC contributed to the conception and design of the study, to data acquisition and analysis, and to data interpretation and manuscript preparation. NB contributed to data analysis and interpretation and to manuscript preparation. GA contributed to data collection and manuscript preparation. FA and AMM contributed to the interpretation of data and manuscript preparation.
JT contributed to the conception and design of the study, to data interpretation and manuscript preparation. All the authors have approved the final version of the manuscript and the attached figures. All the authors have agreed to all aspects of the work.