Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2021 Apr 13.
Published in final edited form as: Eat Behav. 2020 Apr 13;37:101384. doi: 10.1016/j.eatbeh.2020.101384

Negative Beliefs about the Self Prospectively Predict Eating Disorder Severity Among Undergraduate Women

Brenna M Williams 1, Cheri A Levinson 1
PMCID: PMC7246166  NIHMSID: NIHMS1585982  PMID: 32320928

Abstract

Social anxiety disorder (SAD) and eating disorders (EDs) are highly comorbid. Negative self-portrayal, or ‘perceived flaws in the self,’ is a key feature of SAD and consists of three self-critical aspects that are presumed to be flawed: social competence, physical appearance, and signs of anxiety. Negative self-portrayal has yet to be studied among EDs, despite research suggesting that individuals with EDs have a greater negative self-image and self-criticism. The identification of negative self-portrayal as a shared risk factor for SAD and EDs may have important implications for both prevention and treatment. The current study (N = 300 undergraduate women) aimed to extend negative self-portrayal theory to the EDs. We found that several aspects of negative self-portrayal were related to ED severity and that physical appearance concerns predicted subsequent ED severity. In a cross-sectional model of shared vulnerability, we found that physical appearance concerns were a shared correlate of SAD and ED symptoms. In a prospective shared vulnerability model, we found that (a) physical appearance prospectively predicted ED severity and (b) symptoms of SAD prospectively predict all aspects of negative self-portrayal. Concerns about flaws in appearance should be targeted in the treatment of EDs, as this aspect of negative self-portrayal was shown to predict subsequent ED severity. Future research should further investigate the theory of negative self-portrayal as it pertains to EDs.

Keywords: eating disorders, social anxiety, comorbidity, self-criticism

1. Introduction

Eating disorders (EDs) are associated with a variety of poor life outcomes, including higher rates of suicidality, impairment, and distress (Stice, Marti, & Rohde, 2013), as well as increased mortality rates (Birmingham, Su, Hlynsky, Goldner, & Gao, 2005; Klump, Bulik, Kaye, Treasure, & Tyson, 2009). Part of this impairment stems from the high comorbidity with other mental illnesses, including mood, impulse-control, and substance use disorders (Hudson, Hiripi, Pope Jr., & Kessler, 2008). For example, Blinder, Cumella, and Sanathara (2006) found that 97% of ED patients met criteria for at least one other psychiatric diagnosis. Comorbidity in EDs is associated with increased severity of ED symptoms (Spindler & Milos, 2007), increased suicidality (Milos, Spindler, Hepp, & Schnyder, 2004), and impairment in treatment (Milos, Spindler, Buddeberg, & Crameri, 2003), emphasizing the need to expand the field’s understanding of ED comorbidity.

One category of disorder that is highly comorbid with EDs are anxiety disorders, with estimates of comorbidity ranging up to 75% (Hudson et al., 2008). Within the anxiety disorders, social anxiety disorder (SAD) is one of the most common comorbidities, with comorbidity rates estimated up to 68% (Pallister & Waller, 2008). Individuals with EDs are significantly more likely to also have SAD compared to healthy controls (Godart et al., 2003; Halmi, Eckert, Marchi, & Sampugnaro, 1991), and approximately 20% of individuals with SAD also experience ED symptoms (Becker, Deviva, & Zayfert, 2004). SAD may prevent individuals from seeking treatment for EDs (Goodwin & Fitzgibbon, 2002), signifying the importance of studying the mechanisms underlying ED-SAD comorbidity.

A potential mechanism studied in the SAD literature, but not within the ED literature, is negative beliefs about the self. Negative beliefs about the self are defined as ‘perceived flaws in the self’ and are a key feature of SAD (Moscovitch, 2009). Traditional SAD theories propose that the feared stimulus amongst individuals with high SAD is a fear of negative evaluation (Hofmann & Barlow, 2002). However, Moscovitch (2009) proposes a variant of this theory, suggesting that the feared stimulus in SAD is ‘the identification of their perceived flaws’ (rather than general fear of negative evaluation), such as being socially awkward or physically unattractive. Individuals with SAD often believe that they have personal flaws that may be identified by others in social situations, therefore causing others to judge them as insufficient and increasing social anxiety because of worries of exposure of these flaws (see Moscovith, 2009 for a theoretical overview). This fear of exposure of personal flaws may also explain avoidance and safety behaviors, as individuals with social anxiety may attempt to hide their perceived flaws to avoid criticism (Moscovitch et al., 2013). Individuals with this fear may engage in behaviors (e.g., avoidance) that they perceive will hide their flaws. According to a revised model by Moscovitch and Huyder (2011), these flaws are theorized to fall into three categories called negative self-portrayals: social competence (e.g., concerns about being socially awkward), physical appearance (e.g., concerns about being ugly), and signs of anxiety (e.g., concerns about appearing nervous).

Research on negative self-portrayal in the SAD literature suggests that individuals high in social anxiety tend to rate themselves more negatively than controls in a variety of areas, including social skills, physical appearance, and signs of anxiety (Moscovitch, Orr, Rowa, Gehring Reimer, & Antony, 2009). Individuals with SAD also believe that it would be undesirable for them to violate social norms, as their flaws would be identified by others (Moscovitch, Waechter, Bielak, Rowa, & McCabe, 2015). Furthermore, individuals high in social anxiety rate perceived negative consequences of these flaws as more extreme than individuals with low levels of social anxiety (Moscovitch, Rodebaugh, & Hesch, 2012). Finally, individuals with SAD perceive others to be overly critical evaluators with unattainable expectations (Bielak & Moscovitch, 2013; Moscovitch & Hofmann, 2007; Moscovitch et al., 2012), supporting the idea that focusing on perceived flaws and judgment leads to heightened anxiety.

While the theory of negative self-portrayal has been increasingly studied among SAD, it has not been explicitly studied in EDs. However, research on self-esteem and self-image suggest that this theory may be translatable to EDs. For example, individuals with EDs have higher negative self-concept and lower self-esteem in comparison to healthy controls (Jacobi, Paul, de Zwann, Nutzinger, & Dahme, 2004). Bjork et al. (2003) found that individuals with an ED are more likely to have poor self-image than individuals without an ED. Additionally, having a negative self-image is associated with poor treatment outcomes in individuals with EDs (Bjork, Clinton, Sohlberg, & Norring, 2007), showing the importance of understanding negative self-image to improve treatment outcomes. It should be noted that negative self-portrayal is unique from self-esteem in that negative self-portrayal is also concerned with how others will perceive one’s self. The research on self-esteem and self-worth suggest that the theory of negative self-portrayal may contribute to EDs, as individuals with low self-esteem and low self-worth may also have negative self-beliefs (Moscovitch, 2009).

Given the high overlap between SAD and EDs, it seems plausible that negative self-portrayal may be a shared vulnerability among SAD and ED symptoms. Specifically, it seems likely that the domain of negative self-portrayal related to appearance concerns might relate to both SAD and EDs, given the high emphasis on appearance in the EDs (Schwalberg, Barlow, Alger, & Howard, 1992; Utschig, Presnell, Madeley, & Smits, 2010). Moscovitch (2009) proposed that appearance-related concerns are a core feature of SAD, and individuals with EDs tend be particularly concerned about appearance (Koskina, Van den Eynde, Meisel, Campbell, & Schmidt, 2011). Thus, it is possible that negative self-portrayal concerns, specifically those related to appearance, contribute to ED-SAD comorbidity as a shared vulnerability factor. The identification of negative self-portrayal as a shared vulnerability factor for SAD and EDs may suggest the importance of targeting concerns about one’s flaws to prevent the development of both SAD and EDs. Additionally, if negative self-portrayal is a shared vulnerability factor for both disorders, it may be important to target these symptoms in treatment.

Therefore, this study had two aims: to test if negative self-portrayal is related to ED severity; and to test if negative self-portrayal is a shared vulnerability for SAD symptoms and ED severity. We hypothesized that (1) negative self-portrayal would be related to ED severity, and (2) negative self-portrayal, especially those related to appearance concerns, would be a shared vulnerability factor for SAD symptoms and ED severity.

2. Materials and Methods

2.1. Participants

Participants were 300 undergraduate women from a Midwestern university located in the United States. Participants were between the ages of 17 and 23 (M=18.88, SD=1.07). Most participants were European American (n=182, 60.7%), and other ethnicities included Asian (n=82, 27.3), Black (n=12, 4.0%), Hispanic (n=8, 2.7%), and multi-racial (n=15, 5.0%). One participant did not list their ethnicity.

2.2. Procedure

Participants were included in the study if they were biologically female and currently enrolled as an undergraduate student at the university where the study was conducted. Participants were recruited through a university-wide online recruitment system and completed various measures, including the ones described below, at two timepoints approximately three months apart (Time 1 and Time 2). Time 1 measures were completed in-person in the research lab, and Time 2 measures were completed online. Participants received course credit for participating in this study at Time 1. Participants could receive their choice of course credit or a lottery entry for participating in this study at Time 2. The authors assert the all study procedures were conducted in accordance with the Declaration of Helsinki. All procedures were approved by the institution’s Institutional Review Board, and written informed consent was obtained from all participants in-person.

2.3. Measures

2.3.1. Eating Disorder Examination Questionnaire (EDE-Q).

The EDE-Q (Fairburn & Beglin, 1994) is a 28-item self-report questionnaire based off the Eating Disorder Examination (Fairburn & Cooper, 1993). This questionnaire ED-related cognitions and behaviors over the past 28 days via a Likert scale of 0 (no days) to 6 (every day) for most items. A Global score of ED symptoms may be calculated by adding up all four subscales (eating concern, shape concern, weight concern, and restraint) and then dividing by four. The EDE-Q has demonstrated great test-retest reliability and internal consistency (Luce & Crowther, 1999) as well as acceptable criterion and good concurrent validity (Mond, Hay, Rodger, Owen, & Beumont, 2004). The Global score represents an overall construct of symptom severity and has been shown to have the best factor validity (Aardoom, Dingeman, & Slof Op’t Landt, 2012). Internal consistencies for the EDE-Q at both timepoints were excellent (αs=.89–.94)

2.3.2. Negative Self-Portrayal Scale (NSPS).

The NSPS (Moscovitch & Huyder, 2011) is a 27-item questionnaire that assesses concern over exposure of certain self-attributes to others in social situations via a Likert scale of 1 (not at all concerned) to 5 (extremely concerned). The scale measures three factors of negative self-portrayal: social competence (e.g., In social situations, it will become obvious to other people that I am socially awkward), physical appearance (e.g., In social situations, it will become obvious to other people that I am ugly), and signs of anxiety (e.g., In social situations, it will become obvious to other people that I am stuttering). The scale has demonstrated excellent internal consistency and satisfactory test-retest reliability as well as strong convergent and construct validity (Moscovitch & Huyder, 2011; Moscovitch, Rowa, Paulitzki, Antony, & McCabe, 2015). Internal consistencies for the NSPS at both timepoints were acceptable to excellent (αs=.70–.93)

2.3.3. Social Interaction Anxiety Scale (SIAS).

The SIAS (Mattick & Clarke, 1998) is a 20-item questionnaire that measures anxiety in a variety of social situations that involve interaction with others (e.g., When mixing socially, I am uncomfortable; I have difficulty talking with other people) via a Likert scale of 0 (not at all) to 4 (extremely). This measure has demonstrated good to excellent reliability as well a good construct and convergent validity (see Heimberg & Turk, 2002, for a review). The three reverse scored items were omitted because evidence suggests that these items fail to load on the same factor as other items (S-SIAS; Rodebaugh, Woods, Heimberg, Liebowitz, & Schneier, 2006), appear to be more related to extraversion than SAD, and decrease the validity of the scale (Rodebaugh, Woods, & Heimberg, 2007). Removal of these items does not impair the validity of the scale and appears to improve convergent validity (Rodebaugh et al., 2011). We used this measure to assess SAD symptoms. Internal consistencies for the S-SIAS at both timepoints were good (αs=.84).

2.4. Data Analytic Plan

2.4.1. Missing data.

Missing data were estimated automatically using MLR in Mplus Version 8. MLR uses multiple imputation methods including imputation by a constant value and random numbers (Hox, Maas, & Brinkhuis). According to Little’s MCAR test, calculated using SPSS, the data were not missing completely at random (p<.001). Data missing completely at random is an assumption of MLR, thus there may be limitations to the results of this analysis. However, multiple imputation was used which partially offsets this limitation.

2.4.2. Zero-order correlations.

To test our first hypothesis, we calculated zero-order correlations using SPSS between the negative self-portrayal subscales, ED severity, and social interaction anxiety.

2.4.3. Path models.

To test our second hypothesis, Mplus program Version 8 (Muthén & Muthén, 1998–2014) was used to conduct all path modeling using the MLM estimator to produce standardized path estimates. This estimator corrects for any potential violations to multivariate normality. We evaluated model fit using the comparative fit index (CFI; Bentler, 1990), Tucker-Lewis incremental fit index (TLI; Tucker & Lewis, 1973), root mean square error of approximation (RMSEA; Steiger & Lind, 1980), and standardized root mean square residual (SRMR; Jöreskog, 1979). Hu and Bentler (1999) suggested that CFI and TLI values of .90 and above are adequate and values of .95 and above are very good. They also suggested that RMSEA and SRMR values of .08 and below are adequate and values of .05 and are considered very good. For the CFI, TLI, and RMSEA, we used the Swain correction factor for small samples implemented in R to account for the moderate size of the sample (Herzog, Boomsma, & Reinecke, 2007). We first tested the fully saturated models (df=0). Then, we tested the models after removing non-significant paths in order to provide an appropriate test of model fit.

2.4.3.1. Cross sectional model.

We tested a cross-sectional model that included SAD symptoms, ED severity, social competence, physical appearance, and signs of anxiety at Time 1. In this model, SAD symptoms and ED severity were dependent variables, and the three negative self-portrayal aspects were independent variables.

2.4.3.1. Prospective model.

We tested a prospective model that included SAD symptoms, ED severity, social competence, physical appearance, and signs of anxiety at both timepoints. In this model all Time 2 variables were outcomes, and all Time 1 variables were predictors, to account for relationships across time.

3. Results

3.1. Descriptive Statistics

All descriptive statistics can be found in Table 1. All mean scores were within the norms previously found for undergraduate students (Luce Crowther, & Pole, 2008; Mattick & Clarke, 1998; Moscovitch & Huyder, 2011). Using a cut-off score of 2.3 on the EDE-Q, which is indicative of clinical levels of disordered eating (Mond, Hay, Rodgers, Owen, & Beumont, 2004), 19.30% of the sample was at or above the clinical cut-off at Time 1 and 14.60% at Time 2, which is comparable to other female undergraduate samples.

Table 1.

Descriptive statistics of all variables.

Mean (M) Standard Deviation (SD)
T1 ED 1.33 1.06
T1 S-SIAS 22.06 12.23
T1 SC 24.87 9.51
T1 PA 14.84 5.45
T1 SA 14.51 4.60
T2 ED 1.20 0.98
T2 S-SIAS 18.86 11.76
T2 SC 23.37 9.07
T2 PA 14.76 5.85
T2 SA 13.64 4.51
Open in a new tab

Notes: T1 = Time 1, T2 = Time 2, ED = global EDE-Q, S-SIAS = social anxiety disorder symptoms, SC = social competence, PA = physical appearance, SA = signs of anxiety.

3.2. Attrition

Twenty-six out of the 300 participants (8.67%) were lost to follow-up. There was a significant difference in Signs of Anxiety between those who dropped out (M=25.88, SD=11.59) and those who continued the study (M=24.88, SD 9.31); t(296)=−1.47, p=.020). There was also a significant difference in the Global EDE-Q score between those who dropped out (M=1.20, SD=1.34) and those who continued the study (M=1.34, SD=1.03); t(293)=.66, p=.014). There were no other significant differences between those who dropped out and those who continued the study. All missing data were imputed as described above.

3.3. Zero-Order Correlations

All variables were significantly related to each other (rs≥.17, ps≤.006), except for signs of anxiety with Time 1 ED severity, Time 2 ED severity, Time 1 SAD symptoms, and Time 2 SAD symptoms (rs≤.11, ps≥.072). All zero-order correlations can be viewed in Table 2.

Table 2.

Zero-order correlations among negative self-portrayal, ED severity, and social anxiety symptoms.

N = 300 T1 SC T1 PA T1 SA T1 ED T1 S-SIAS T2 SC T2 PA T2 SA T2 ED T2 S-SIAS
T1 SC
T1 PA .62*
T1 SA .53** .40**
T1 ED 19** .49** .11
T1 S-SIAS .76** .55** .51** .26**
T2 SC 73** .51** .35** .22** .65**
T2 PA 44** .77** .25** .43** .47** .61**
T2 SA .35** .30** .61** .03 .42** .54** .43**
T2 ED 17** .46** .02 .84** .21** .26** .52** .09
T2 S-SIAS .62** .49** .37** .21** .81** .77** .57** .52** .23**
Open in a new tab

Notes: T1 = Time 1, T2 = Time 2, SC = social competence, PA = physical appearance, SA = signs of anxiety, ED = global EDE-Q, S-SIAS = social anxiety disorder symptoms;

**

p < .05.

3.4. Cross-Sectional Model

The initial model had perfect fit (CFI=1.00, TLI=1.00, RMSEA=0.00, SRMR=0.00), indicating that the model was saturated. After removing non-significant paths, the model was no longer saturated and fit was adequate to excellent (CFI=.98, TLI=.94, RMSEA=.09, SRMR=.03). The Swain Correction slightly improved fit (CFI=.99, TLI=.95, RMSEA=.09). As Figure 1 shows, of the aspects of negative self-portrayal, only physical appearance was significantly associated with ED severity (p<.001). All aspects of negative self-portrayal were significantly associated with SAD symptoms (ps≤.030). ED severity and SAD symptoms were significantly related (r=.23, p≤.001) when the aspects of negative self-portrayal were not accounted for. However, when accounting for the aspects of negative self-portrayal, ED severity and SAD symptoms were no longer significantly related (p=.165).

Figure 1.

Figure 1.

Open in a new tab

Cross-sectional path model of negative self-portrayal associated with ED severity and SAD symptoms. Notes: All paths were computed, and only significant paths are shown for ease of interpretation. ED = eating disorder, SAD = social anxiety disorder; *p < .05, **p < .01.

3.5. Prospective Model

The initial model had perfect fit (CFI=1.00, TLI=1.00, RMSEA=0.00, SRMR=0.00), again indicating that the model was saturated. Fit was excellent when non-significant paths were removed (CFI=1.00, TLI=0.99, RMSEA=.04, SRMR=.03). The Swain correction indicated that fit was excellent (CFI=1.00, TLI=0.99, RMSEA=.04). As Figure 2 shows, Time 1 physical appearance significantly prospectively predicted Time 2 ED severity (p=.016). Time 1 SAD symptoms significantly prospectively predicted Time 2 social competence, physical appearance, and signs of anxiety (ps≤.034). There were no other significant prospective predictors.

Figure 2.

Figure 2.

Open in a new tab

Prospective path model of negative self-portrayal, ED severity, and SAD symptoms. Notes: All paths were computed, and only significant paths are shown for ease of interpretation; Autoregressive paths are dashed lines. ED = eating disorder, SAD = social anxiety disorder; *p < .05, **p < .01.

4. Discussion

Overall, we found partial support for the theory of negative self-portrayal in relation to ED symptoms, in that concerns about physical appearance were significantly associated with and significantly predicted ED severity, suggesting this aspect of negative self-portrayal is most related to EDs. This finding suggests that future research is warranted to continue to extend this theory into EDs. We found that several aspects of negative self-portrayal had associations with ED severity, particularly social competence and physical appearance. We also found that concerns about flaws in one’s appearance was a prospective predictor of ED severity. These findings suggest that concerns about flaws in one’s appearance are an important feature of self-criticism that warrants future research and attention in clinical practice and may increase the risk greater ED severity.

Regarding our cross-sectional model, we found that physical appearance concerns were a shared correlate of both SAD symptoms and ED severity. In other words, concerns about perceived flaws in one’s physical appearance are concurrently related to both SAD and ED symptoms. It is possible that these perceived flaws in one’s appearance may contribute to the high rates of comorbidity between EDs and SAD. These findings suggest that individuals with SAD-ED comorbidity should be assessed for negative self-portrayal, especially regarding physical appearance. We also found that ED severity and SAD symptoms were no longer significantly related when accounting for the aspects of negative self-portrayal. This finding suggests that negative self-portrayals may account for the relationship between EDs and SAD. However, we cannot conclude this relationship with the current study model as we only have two timepoints. Future research should investigate negative self-portrayal as a mediator of the relationship between EDs and SAD using three timepoints (Maxwell & Cole, 2007).

Our prospective model slightly diverged from our cross-sectional model, such that only physical appearance concerns prospectively predicted ED severity and there were no significant predictors of SAD symptoms. Surprisingly, we found that SAD symptoms prospectively predicted all aspects of negative self-portrayal, which is opposite to what the theory might suggest. These findings suggest that SAD may lead to negative self-portrayal, instead of in the other direction. It is possible that this finding was a product of our college-aged sample, as SAD normally has developed prior to this age (Grant et al., 2005). Negative self-portrayal may prospectively predict SAD in younger adolescents. Furthermore, these findings suggest that negative self-portrayal, particularly regarding physical appearance, may lead to the development of ED symptoms. Additionally, as the EDE-Q Global score encompasses body image concerns, and physical appearance concerns predicted ED symptoms over and above general concerns about body and weight, our results suggest that there is a unique aspect of physical appearance concerns that is related to ED symptoms. Previous research has indicated that anxiety disorders frequently precede the development of EDs (Bulik, Sullivan, Carter, & Joyce, 1996; Deep, Nagy, Weltzin, Rao, & Kaye, 1995), suggesting that it may be beneficial to target negative self-portrayal in order to prevent the future development of EDs and minimize severity of ED symptoms. Future research should continue to identify how negative self-portrayal varies from negative self-esteem.

The prospective prediction of ED severity is especially important given prior research showing ED severity is associated with low quality of life (Bamford & Sly, 2010) and higher frequency of purging behaviors (Edler, Haedt, & Keel, 2007) Concerns about flaws in one’s appearance could be targeted in treatment, as these aspects of negative self-portrayal were shown to prospectively predict ED severity. Clinicians should also consider targeting negative self-portrayal when treating SAD, as it may prevent the development of future ED symptoms. Furthermore, future treatment development focused on targeting negative self-portrayal is needed. Individuals experiencing SAD and ED symptoms may benefit from exposure therapy concentrated on the fear of exposing their perceived flaws to others (Moscovitch et al., 2012), as well as cognitive restructuring and challenging core beliefs surrounding their perceived flaws (Moscovitch et al., 2013). Cognitive behavioral treatment for EDs (CBT-E; Fairburn, 2008) currently utilizes cognitive restructuring and challenging core beliefs, and it may be particularly beneficial to add a component of exposure to target the fear that others will identify flaws in one’s physical appearance.

There were several limitations present in this study. First, this study relied on self-report measures and is therefore limited by self-awareness and self-report biases (Dymond & Barnes, 1997). Also, our sample was undergraduate and female-only, and therefore, we are unable to generalize beyond these populations. Keeping these limitations in mind, future research should focus on including more diverse samples, including those with males, to promote more generalizable findings. It may also be beneficial to study negative self-portrayal in a clinical sample, including that of individuals with binge eating disorder, as the results may ensure better understanding of the underlying mechanisms of negative self-portrayal among SAD and ED symptoms. Furthermore, as physical appearance concerns predicted ED severity in this sample, future research should assess whether negative self-portrayal predicts specific ED symptoms and behaviors.

5. Conclusions

In conclusion, we found initial support for the theory of negative-self portrayal, particularly that of physical appearance, and it’s relation with ED symptoms and behaviors. Specifically, we found that concerns about flaws in appearance predicted later ED severity. Therefore, it may be beneficial to target negative self-portrayal concerns, specifically those related to concerns about flaws in one’s appearance, as it may prevent the future development of ED symptoms and minimize ED severity.

Highlights.

  • Negative beliefs about the self are related to eating disorder severity

  • Social anxiety disorder symptoms predicted negative beliefs about the self

  • Negative beliefs about one’s physical appearance predicted eating disorder severity

Role of Funding Sources

Funding for this study was provided by NIMH F31-MH096433 to Cheri A. Levinson. NIMH had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

This research was supported by NIMH F31-MH096433 to Cheri A. Levinson.

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Conflict of Interest

There are no conflicts of interests to disclose.

References

  1. Aardoom JJ, Dingemans AE, Slof Op’t Landt MCT, & Van Furth EF (2012). Norms and discriminative validity of the Eating Disorder Examination Questionnaire (EDE-Q). Eating Behaviors, 13, 305–309. DOI: 10.1016/j.eatbeh.2012.09.002 [DOI] [PubMed] [Google Scholar]
  2. Bamford B & Sly R (2010). Exploring quality of life in the eating disorders. European Eating Disorders Review, 18, 147–153. DOI: 10.1002/erv.975 [DOI] [PubMed] [Google Scholar]
  3. Becker CB, DeViva JC, & Zayfert C (2004). Eating disorder symptoms among female anxiety disorder patients in clinical practice: The importance of anxiety comorbidity assessment. Journal of Anxiety Disorders, 18, 255–274. DOI: 10.1016/S0887-6185(03)00002-1 [DOI] [PubMed] [Google Scholar]
  4. Bentler PM (1990). Comparative Fit Indexes in Structural Models. Psychological Bulletin, 107, 238–246 [DOI] [PubMed] [Google Scholar]
  5. Bielak T & Moscovitch DA (2013). How do I measure up? The impact of observable signs of anxiety and confidence on interpersonal evaluations in social anxiety. Cognitive Therapy and Research, 37, 266–276. DOI: 10.1007/s10608-012-9473-4 [DOI] [Google Scholar]
  6. Birmingham CL, Su J, Hlynsky JA, Goldner EM, & Gao M (2005). The mortality rate from anorexia nervosa. International Journal of Eating Disorders, 38, 143–146. DOI: 10.1002/eat20164. [DOI] [PubMed] [Google Scholar]
  7. Bjork C, Clinton D, Sohlberg S, Hallstrom T, & Norring C (2003). Interpersonal profiles in eating disorders: Rating of SASB self-image. Psychology and Psychotherapy: Theory, Research, and Practice, 76, 337–349. [DOI] [PubMed] [Google Scholar]
  8. Bjork C, Clinton D, Sohlberg S, & Norring C (2007). Negative self-image and outcome in eating disorders: Results at 3-year follow-up. Eating Behaviors, 8, 398–406. DOI: 10.1016/j.eatbeh.2006.12.002 [DOI] [PubMed] [Google Scholar]
  9. Blinder BJ, Cumella EJ, Santhara VA (2006). Psychiatric comorbidities of female inpatients with eating disorders. Psychosomatic Medicine, 63, 454–462. DOI: 10.1097/01.psy.0000221254.77675.f5 [DOI] [PubMed] [Google Scholar]
  10. Bulik CM, Sullivan PF, Fear JI, & Joyce PR (1997). Eating disorders and antecedent anxiety disorders: A controlled study. Acta Psychiatrica Scandinavica, 96, 101–107. DOI: 10.1111/j.1600-0447.1997.tb09913.x [DOI] [PubMed] [Google Scholar]
  11. Deep AL, Nagy LM, Weltzin TE, Rao R, & Kaye WH (1995). Premorbid onset of psychopathology in long-term recovered anorexia nervosa. International Journal of Eating Disorders, 17, 291–297. DOI: [DOI] [PubMed] [Google Scholar]
  12. Dymond S, & Barnes D (1997). Behavior-analytic approaches to self-awareness. The Psychological Record, 47, 181–200. [Google Scholar]
  13. Edler C Haedt AA, & Keel PK (2007). The use of multiple purging methods as an indicator of eating disorder severity. International Journal of Eating Disorders, 40, 515–520. DOI: 10.1002/eat.20416 [DOI] [PubMed] [Google Scholar]
  14. Fairburn CG & Beglin SJ (1994). Assessment of eating disorders: Interview or self-report questionnaire? International Journal of Eating Disorders, 16, 363–370. DOI: [DOI] [PubMed] [Google Scholar]
  15. Fairburn CG & Cooper Z (1993). The Eating Disorder Examination (12th edition). In Fairburn CG & Wilson GT (Eds.), Binge eating: Nature, assessment, and treatment (pp. 317–360). New York, NY, US: Guilford Press. [Google Scholar]
  16. Godart NT, Flament MF, Curt F, Perdereau F, Lang F, Venisse JL, … & Fermanian J (2003). Anxiety disorders in subjects seeking treatment for eating disorders: A DSMIV controlled study. Psychiatry Research, 117, 245–258. DOI: 10.1016/S0165-1781(03)00038-6 [DOI] [PubMed] [Google Scholar]
  17. Goodwin RD, & Fitzgibbon ML (2002). Social anxiety as a barrier to treatment for eating disorders. International Journal of Eating Disorders, 32, 103–106. DOI: 10.1002/eat.10051 [DOI] [PubMed] [Google Scholar]
  18. Grant BF, Hasin DS, Blanco C, Stinson FS, Chou SP, Goldstein RB, … & Huang B (2005). The epidemiology of social anxiety disorder in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 66, 1351–1361. DOI: 10.4088/JCP.v66n1102 [DOI] [PubMed] [Google Scholar]
  19. Fairburn CG (2008). Cognitive Behavior and Eating Disorders. New York: Guilford Press. [Google Scholar]
  20. Halmi KA, Eckert E, Marchi P, & Sampugnaro V (1991). Comorbidity of psychiatric diagnoses in anorexia nervosa. Archives of General Psychiatry, 48, 712–718. DOI: 10.1001/archpsyc.1991.01910320036006 [DOI] [PubMed] [Google Scholar]
  21. Heimberg RG, & Turk CL (2002). Assessment of social phobia In Heimberg RG & Becker RE (Eds), Cognitive-Behavioral Group Therapy for Social Phobia: Basic Mechanisms and Clinical Strategies (pp. 107–126). New York, NY: Guilford Press. [Google Scholar]
  22. Herzog W, Boomsma A, & Reinecke S (2007). The model-size effect on traditional and modified tests of covariance structures. Structural Equation Modeling, 14, 361–390. DOI: 10.1080/10705510701301602 [DOI] [Google Scholar]
  23. Hofmann SG & Barlow DH (2002). Social phobia (social anxiety disorder) In Barlow DH (Ed), Anxiety and Its Disorders: The Nature and Treatment of Panic (pp. 454–476). New York, NY: Guilford Press. [Google Scholar]
  24. Hu LT, & Bentler PM (1999). Cutoff Criteria for Fit Indexes in Covariance Structure Analysis: Conventional Criteria Versus New Alternatives. Structural Equation Modeling-a Multidisciplinary Journal, 6, 1–55 [Google Scholar]
  25. Hudson JI, Hiripi E Pope HG Jr., & Kessler RC (2008). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61, 348–358. DOI: 10.1016/j.bio.psych.2006.03.040 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Jacobi C, Paul T, de Zwann M, Nutzinger DO, & Dahme B (2004). Specificity of self-concept disturbances in eating disorders. International Journal of Eating Disorders, 35, 204–210. DOI: 10.1002/eat.10240 [DOI] [PubMed] [Google Scholar]
  27. Jöreskog KG (1979). Statistical estimation of structural models in longitudinal-developmental investigations (Nesselroade JR & Baltes PB (Eds.), Longitudinal Research in the Study of Behavior and Development (pp. 303–374). New York: Academic Press. [Google Scholar]
  28. Klump KL, Bulik CM, Kaye WH, Treasure J, & Tyson E (2009). Academy for Eating Disorders position paper: Eating disorders are serious mental illnesses. International Journal of Eating Disorders, 42, 97–103. DOI: 10.1002/eat.20589 [DOI] [PubMed] [Google Scholar]
  29. Koskina A, Van den Eynde F, Meisel S, Campbell IC, & Schmidt U (2011). Social appearance anxiety and bulimia nervosa. Eating and Weight Disorders – Studies on Anorexia, Bulimia, and Obesity, 16, e142–e145. DOI: 10.1007/BF03325231 [DOI] [PubMed] [Google Scholar]
  30. Luce KH & Crowther JH (1999). The reliability of the Eating Disorder Examination-Self-Report Questionnaire version (EDE-Q). International Journal of Eating Disorders, 25, 349–351. DOI: 10.1002(SICI)1098-108X(199904)25:3<349::AID-EAT15>3.0.CO;2-M [DOI] [PubMed] [Google Scholar]
  31. Luce KH, Crowther JH, & Pole M (2008). Eating Disorder Examination Questionnaire (EDE-Q) norms for undergraduate women. International Journal of Eating Disorders, 41, 273–276. DOI: 10.1002/eat.20504 [DOI] [PubMed] [Google Scholar]
  32. Mattick RP & Clarke JC (1998). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behaviour Research and Therapy, 36, 455–470. DOI: 10.1016/S0005-7967(97)10031-6 [DOI] [PubMed] [Google Scholar]
  33. Maxwell SE, & Cole DA (2007). Bias in cross-sectional analyses of longitudinal mediation. Psychological Methods, 12, 23–44. DOI: 10.1037/1082-989X.12.1.23 [DOI] [PubMed] [Google Scholar]
  34. Milos GF, Spindler AM, Buddeberg C, & Crameri A (2003). Axes I and II comorbidity and treatment experiences in eating disorder subjects. Psychotherapy and Psychosomatics, 72, 276–285. DOI: 10.1159/000071899 [DOI] [PubMed] [Google Scholar]
  35. Milos G, Spindler A, Hepp U, & Schnyder U (2004). Suicide attempts and suicidal ideation: Links with psychiatric comorbidity in eating disorder subjects. General Hospital Psychiatry, 26, 129–135. DOI: 10.1016/j.genhosppsych.2003.10.005 [DOI] [PubMed] [Google Scholar]
  36. Mond JM, Hay PJ, Rodgers B, Owen C, & Beumont PJ (2004). Validity of the Eating Disorder Examination Questionnaire (EDE-Q) in screening for eating disorders in community samples. Behavior Research and Therapy, 42, 551–567. DOI: 10.1016/S0005-7967(03)00161-X [DOI] [PubMed] [Google Scholar]
  37. Moscovitch DA (2009). What is the core fear in social phobia? A new model to facilitate individualized case conceptualization and treatment. Cognitive and Behavioral Practice, 16, 123–134. DOI: 10.1016/j.cbpra.2008.04.002 [DOI] [Google Scholar]
  38. Moscovitch DA & Hofmann SG (2007). When ambiguity hurts: Social standards moderate self-appraisals in generalized social phobia. Behaviour Research and Therapy, 45, 1039–1052. DOI: 10.1016/j.brat.2006.07.008 [DOI] [PubMed] [Google Scholar]
  39. Moscovitch DA & Huyder V (2011). The Negative Self-Portrayal Scale: Development, validation, and application to social anxiety. Behavior Therapy, 42, 183–196. DOI: 10.1016/j.beth.2010.04.007 [DOI] [PubMed] [Google Scholar]
  40. Moscovitch DA, Orr E Rowa K, Gehring Reimer S, & Antony MM (2009). In the absence of rose-colored glasses: Ratings of self-attributes and their differential certainty and importance across multiple dimensions in social phobia. Behaviour Research and Therapy, 47, 66–70. DOI: 10.1016/j.brat.2008.10.007 [DOI] [PubMed] [Google Scholar]
  41. Moscovitch DA, Rodebaugh TL, & Hesch BD (2012). How awkward! Social anxiety and the perceived consequences of social blunders. Behaviour Research and Therapy, 50, 142–149. DOI: 10.1016/j.brat.2011.11.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Moscovitch DA, Rowa K, Paulitzki JR, Antony MM, & McCabe RE (2015). What if I appear boring, anxious, or unattractive? Validation and treatment sensitivity of the Negative Self Portrayal Scale in clinical samples. Cognitive Therapy and Research, 39, 178–192. DOI: 10.1007/s10608-014-9645-5 [DOI] [Google Scholar]
  43. Moscovitch DA, Rowa K, Paulitzki JR, Ierullo MD, Chiang B, Antony MM, & McCabe RE (2013). Self-portrayal concerns and their relation to safety behaviors and negative affect in social anxiety disorder. Behaviour Research and Therapy, 51, 476–486. DOI: 10.1016/j.brat.2013.05.002 [DOI] [PubMed] [Google Scholar]
  44. Moscovitch DA, Waechter S, Bielak T, Rowa K, McCabe RE (2015). Out of the shadows and into the spotlight: Social blunders fuel fear of self-exposure in social anxiety disorder. Journal of Anxiety Disorders, 24, 24–32. DOI: 10.1016/j.janxdis.2015.06.004 [DOI] [PubMed] [Google Scholar]
  45. Muthén LK, & Muthén BO (1998–2014). Mplus User’s Guide. Seventh Ed. Vol. Los Angeles, CA: Muthén & Muthén. [Google Scholar]
  46. Pallister E & Waller G (2008). Anxiety in the eating disorders: Understanding the overlap. Clinical Psychology Review, 28, 366–386. DOI: 10.1016/j.cpr.2007.07.001 [DOI] [PubMed] [Google Scholar]
  47. Rodebaugh TL, Heimberg RG, Brown PJ, Fernandez KC, Blanco C, Schneier FR, & Liebowitz MR (2011). More reasons to be straightforward: Findings and norms for two scales relevant to social anxiety. Journal of Anxiety Disorders, 25, 623–630. DOI: 10.1016/j.janxdis.2011.02.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Rodebaugh TL, Woods CM, & Heimberg RG (2007). The reverse of social anxiety is not always the opposite: The reverse-scored items of the social interaction anxiety scale do not belong. Behavior Therapy, 38, 192–206. DOI: 10.1016/j.beth.2006.08.001 [DOI] [PubMed] [Google Scholar]
  49. Rodebaugh TL, Woods CM, Heimberg RG, Liebowitz MR, & Schneier FR (2006). The factor structure and screening utility of the Social Interaction Anxiety Scale. Psychological Assessment, 18, 231–237. DOI: 10.1037/1040-3590.18.2.231 [DOI] [PubMed] [Google Scholar]
  50. Schwalberg MD, Barlow DH, Alger SA, & Howard LJ (1992). Comparison of bulimics, obese binge eaters, social phobics, and individuals with panic disorder on comorbidity across DSM-III—R anxiety disorders. Journal of Abnormal Psychology, 101, 675–681. DOI: 10.1037/0021-843X.101.4.675 [DOI] [PubMed] [Google Scholar]
  51. Spindler A & Milos G (2007). Links between eating disorder symptoms severity and psychiatric comorbidity. Eating Behaviors, 8, 364–373. DOI: 10.1016/j.eatbeh.2006.11.1012 [DOI] [PubMed] [Google Scholar]
  52. Steiger JH, & Lind JC (1980). Statistically-based tests for the number of factors. Paper presented at the Annual Spring Meeting of the Psychometric Society, Iowa City, Iowa. [Google Scholar]
  53. Stice E, Marti CN, & Rohde P (2013). Prevalence, incidence, impairment, and course of the proposed DSM-5 eating disorder diagnoses in an 8-year prospective community sample of young women. Journal of Abnormal Psychology, 122, 445–457. DOI: 10.1037/a0030678 [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Tucker L, & Lewis C (1973). A reliability coefficient for maximum likelihood factor analysis. Psychometrika, 38, 1–10. [Google Scholar]
  55. Utschig AC, Presnell K, Madeley MC, & Smits JAJ (2010). An investigation of the relationship between fear of negative evaluation and bulimic psychopathology. Eating Behaviors, 11, 231–238. DOI: 10.1016/j.eatbeh.2010.05.003 [DOI] [PubMed] [Google Scholar]

RESOURCES