Amalia Hartman
Dr. Edmond
PSYC 213
23 July 2014
Research Review Paper: Comorbidity in GAD and Anorexia Nervosa
The comorbidity for generalized anxiety disorder and anorexia nervosa is wellestablished. Up to 40% of women with anorexia nervosa also have a lifelong history with
generalized anxiety disorder (Dellava, Kendler & Neale, 2011). In researching the association of
generalized anxiety disorder and anorexia nervosa, it seemed that many of the journal articles
had similar basic ideas. The guiding principles of the journal articles included symptoms of both
disorders, possible explanations for comorbidity, and various treatment strategies. Lastly, the
various journal articles themselves gave great insight into the comorbidity for generalized
anxiety disorder and anorexia nervosa by explaining the experiments that took place and the
results that were concluded.
Anorexia nervosa has a distinct relationship with anxiety disorders. According to Virginia
Commonwealth University, “women with anorexia nervosa were more than six times more likely
than women without anorexia nervosa to have generalized anxiety and conversely, women with
generalized anxiety disorder were approximately six times more likely to have anorexia nervosa
than women without generalized anxiety disorder” (Dellava, Kendeler & Neale, 2011, p.728).
These individuals have common temperamental patterns and personality characteristics that are
found in both anorexia nervosa and anxiety disorders (Dellava, Kendeler & Neale, 2011). Some
examples of temperamental and personality characteristics are, “elevated levels of perfectionism,
rigidity, compulsivity and harm avoidance” (Dellava, Kendeler & Neale, 2011, p.730).
Many experimental studies have been done in order to observe possible reasons for the
comorbidity of generalized anxiety disorder and anorexia nervosa. The Virginia Adult Twin
Study of Psychiatric and Substance Use Disorders concluded that, “generalized anxiety disorder
and anorexia nervosa share a modest portion of genetic and unique environmental liability and
these seem responsible for the comorbidity between GAD and AN” (Dellava, Kendeler & Neale,
2011, p. 732). For example, women who had high anxiety were also identified as individuals
who exercised avidly. More specifically, this study hypothesized that “there is a phenotypic
causal relationship between GAD and AN, evidenced by phenotypic commonalities” (Dellava,
Kendeler & Neale, 2011, p.728). The results show that the genetic correlation between the two
disorders was .20, while the unique environmental correlation was .18 (Dellava, Kendeler &
Neale, 2011, p.728). Another possible explanation for the comorbidity of generalized anxiety
disorder and anorexia nervosa is explained through a study that looked at the functional
relationships of triggers, anxiety and anorexia nervosa. The most prevalent links between
anxious emotions and eating disorders were threat appraisal and the perception of uncertainty.
The journal explains that “threat appraisal is a defining aspect of anorexia nervosa pathology
supported by observation of attentional bias towards threatening stimuli common among those
with eating disorder” (Hildebrandt, Bacow, Markella & Loeb, 2010, p. 6). Some of the most
common appraising triggers reported from patients with anorexia nervosa include food, eating,
shape and weight as threats to their body appearance, weight and social status (Hildebrandt,
Bacow, Markella & Loeb, 2010). The study also explains how the perception of uncertainty links
generalized anxiety disorder and anorexia nervosa. “In the case of anorexia nervosa, when a task
involves a high degree of uncertainty (e.g. food of unknown caloric density or predictive impact
on future weight status), the consequence is increased brain arousal” (Hildebrandt, Bacow,
Markella & Loeb, 2010, p. 7). For instance, if an individual is given a slice of pizza to eat, she
may become extremely worried and anxious about how many calories it contains or how much
weight she will gain from consuming it. Furthermore, she may begin to avoid pizza altogether.
According to the study, “over time, repeated avoidance reinforces the anxiety because of limited
access to competing information and anxiety generalizes to other triggers through associative
learning” (Hildebrandt, Bacow, Markella & Loeb, 2010, p.7).
There are various treatment strategies that could be used to treat both anorexia nervosa
and generalized anxiety disorder. The three main treatment strategies discussed included familybased treatment, cognitive-behavioral therapy and exposure based therapy. The family-based
treatment approach is described by a treatment that, “actively enlists the parents in the process of
their adolescent’s recovery, temporarily giving them the authority to make decisions about their
child’s food intake and facilitate nutritional rehabilitation until resistance and anorexia nervosa
symptoms begin to fade. Then, control over eating is transferred back to the adult” (Hildebrandt,
Bacow, Markella & Loeb, 2010, p. 2). Instead of pleading with the individual to eat, familybased therapy simply does not allow self-starvation to be an option. However, to work with the
anxiety that is comorbid to anorexia nervosa, family-based therapy also involves some basic
exposure principles. A functional example of exposure principles in family-based therapy is, “the
exposure of unknown quantity, calories or macronutrient content in the re-feeding process
spearheaded by the parents allows for an improved confidence in that one can eat safely even
when uncertain of the contents of the food” (Hildebrandt, Bacow, Markella & Loeb, 2010, p. 9).
Thus, the individual will no longer feel the worry or anxiety that usually entails food
consumption. Another treatment strategy widely used by psychologists is cognitive-behavioral
therapy. Exposure is a vital ingredient used in cognitive-behavioral therapy, because it has been
proven effective in symptom reduction (Hildebrandt, Bacow, Markella & Loeb, 2010).
Furthermore, a key concept of cognitive-behavioral therapy is ‘transfer of control’. In this
concept model there is a gradual transfer of knowledge and methods from the therapist, then to
the parent and eventually to the child (Hildebrandt, Bacow, Markella & Loeb, 2010).
All of the journal articles were based on experiments done to prove or disprove their
hypotheses about the comorbidity for anorexia nervosa and anxiety disorders. However, the
hypotheses developed by the psychologists involved different aspects to study in this
comorbidity. For example, one objective stated that the researchers, “examined the influence of
depression and anxiety on executive function in individuals with a DSM-IV diagnosis of
anorexia nervosa-restricting type” (Billingsley- Marshall, Basso, Lund, Hernandez, Johnson,
Drevets, McKee & Yates, 2013, p.316). This experiment focused solely on the impact that
lessened executive function ability due to anxiety had on anorexia nervosa patients. Also
focusing on the reasoning for comorbidity for anorexia nervosa and generalized anxiety disorder,
was the Virginia Commonwealth University study. The aim of the experiment done was, “to seek
to elucidate the shared genetic and environmental components between generalized anxiety
disorder and anorexia nervosa” (Dellava, Kendeler & Neale, 2011, p.728). Another journal
article focused more on treatment methods, mainly family-based therapy, than the reasons for
comorbidity. This experiment, “suggested that family-based therapy may work via exposure (and
habituation) to food and its consumption” (Hildebrandt, Bacow, Markella & Loeb, 2010, p.1).
Thus, all of these experiments had a central focus on the comorbidity for anorexia nervosa and
generalized anxiety disorder.
The lifetime prevalence of generalized anxiety disorder and anorexia nervosa is estimated
to be about 31% and 24%, respectively (Swinbourne & Touyz, 2007). Furthermore, “13% of
their anorexia nervosa and bulimia nervosa subjects met the criteria for generalized anxiety
disorder” (Swinbourne & Touyz, 2007, p. 269). It is proven through experimental data that there
is a high rate of comorbidity for generalized anxiety disorder and anorexia nervosa. Because of
various research findings, psychologists and psychiatrists are better able to recognize the
personality and temperamental characteristics that correlate with generalized anxiety disorder
and anorexia nervosa. Thus, diagnoses and treatment strategies are becoming more easily
available to those in need.
References
Billingsley-Marshall, R. L., Basso, M. R., Lund, B. C., Hernandez, E. R., Johnson, C.L., Drevets,
W.C.,… Yates, W. R. (2013). Executive Function in Eating Disorders: The Role of State
Anxiety. International Journal of Eating Disorders, 46:4, 316-321.
Dellava, J. E., Kendler, K. S. & Neale, M.C. (2011). Generalized Anxiety Disorder and Anorexia
Nervosa: Evidence of Shared Genetic Variation. Depression and Anxiety, 28, 728-733.
Hildebrandt, T., Bacow, T., Markella, M. & Loeb, K. (2012). Anxiety in Anorexia Nervosa and
its Management Using Family-Based Treatment. European Eating Disorders Review, 20,
1-17.
Swinbourne, J. M. & Touyz, S. W. (2007). Co-Morbidity of Eating Disorder and Anxiety
Disorders: A Review. European Eating Disorders Review, 15, 253-274.