TABLE 4.

Themes and sub-themes derived from focus groups with patients, carers and professionals.

Theme	Patients	Carers	Professionals
Virtual rejection/exclusion	“oh yeah and like posting photos and seeing how many likes/followers you have seems risky” “or you might worry they think you look fat/might not comment on you being skinny” “after I was discharged from hospital one of my friends always talked about the chat with my other friends who I walked to school with knowing full well I wasn’t in the chat”	“with social media, my daughter gets very concerned if she doesn’t get immediate responses to messages as she thinks she is being ignored. She doesn’t post much and in fact took down most of her social media during her GCSE’s.” “the “likes” on social media seems to be the way to judge popularity. My daughter used to spend ages trying to take a good photo to put on Instagram and would continuously check the likes and comments” “Yes online media is a nightmare for someone who has major anxieties, low self- esteem etc., Constantly looking for the number of ‘likes’ - spending hours over which picture to post and which caption she should add in case it is laughed at/ridiculed by others”	“seeing friends message each other on social media and not being included, seeing photos of friends hanging out at parties, etc., that they haven’t been invited to” “Not invited to parties and seeing this on the social media or being “blanked” by their peers, getting silent treatment” “friends taking a while to reply to messages” “I have seen young people feel so uncontrollably anxious that they have had panic attacks because friends have not texted them back and they are sure their entire social network has been lost.” “they would essentially go into a full-blown panic and experience severe anxiety if they did not receive enough likes on their post or if people unfriended them or unfollowed them or did not follow them back”
Rejection associated with an aspect of the eating disorder	“they go out for a meal but don’t invite you I have also had it happen when they go for a meal but don’t invite you or your best friend either because they don’t want you to feel left out” “Exactly, and sometimes it’s not just meals but on someone’s birthday they might bring in food but won’t ask if you want some or something along those lines” “Another example I had was my close friends all went out to play tennis and didn’t even ask as they assumed, I couldn’t do it”	“family gatherings with lots of food and expectations were also a problem for us at the time. Harmless statements such as “you’re up for dessert seconds” (dessert was never a problem) could send her into a tailspin” “Oh, the stresses of what to wear! it could take hours for her to get ready and the smallest of comments could send her back upstairs to get changed again!” “at present she is isolated and avoiding situations where she feels people are looking at her and judging (to be fair people are looking at her. her BMI is 13 and she looks ill, so it is natural for people to look). Sometimes she has felt excluded so has tried to be popular by dressing up (when she at a healthier weight she is stunning) and getting the boys attention.”	“or friends going out for lunch/to a party/to dinner and not inviting them because of the food element” “some negative comments from others about how thin they are, particularly from boys in their school, things like ‘you might snap’ I have heard quite a few times maybe partly due to fear that their peers would not see them as having an eating disorder, or thinking that they are ‘getting better’ a person who wasn’t selected for their sports team because they really weren’t well enough and they really took it to heart - it seemed to really impact their (already low) self-esteem and it was like it was a personal slight against them rather than a reflection of how poorly they were” “there was a lot of assumed rejection or criticism relating to competitiveness - so some young people might sit on the edge of their seat or stand for long periods of time so others would not judge them as lazy or not struggling during meal times, the food would be consumed very slowly, kind of like the opposite of a race”
Rejection triggered by ambiguous/benign comments or behaviors from others	“also people with eating disorders might misinterpret situations and react more negatively compared to people without who might not be upset by it” “Yes I agree with p4 definitely over think the reason you weren’t invited.” “Yes definitely organizing something with friends because sometimes if they don’t reply you might think they don’t want to come etc”	“I agree that you have to be very careful what words you use. A friend of mine said my daughter looked really well once and my daughter took that as she had put on too much weight.” “yesterday I commented to my daughter that her eyes looked brighter and she didn’t look so dehydrated. This translated into her mind as she looks like she has put on weight and looking healthier. she promptly shouted at me that I am triggering and went upstairs to weigh herself” “our daughter was constantly saying that teachers at school gave her “dirty looks” and was convinced that one subject teacher did not want her to study a subject at A	“Yeah, you look well doesn’t go down well!” “it is almost like any situation could make them feel rejected depending on even subtle reactions of the people they are with finding friends at lunch times and people not looking up straight away to say hello, or not moving over for them to sit in the group comfortably; peers finishing their conversations with other peers before greeting them; peers not really looking at them when they are talking in a group” people not asking them how they are (yet being asked also causes anxiety); people not making the effort to speak to them first; other ones might include seeing peers whispering and the young people believing they are
		Level. I had to ask the School to confirm if that was the case and they said absolutely not and that the teacher had no concerns over her ability”	speaking about them in a negative way, which might make them withdraw from those individuals.” “a young person could pay a compliment to another young person about their dress, and then would seek reassurance from a staff member that they have not just made the other young people feel bad/negative about their looks (if that makes sense) - so a lot of second guessing and worrying about what they say and do - and I guess worrying that this would lead to being socially rejected”
Rejection perceived when confiding in others	“when you tell a friend or someone else about the eating disorder and they don’t believe you/dismiss it” “I haven’t told anyone about my problem sometimes it feels to daunting to confront them about it, so sometimes I just leave it. I wouldn’t tell them how I felt because I would fear being rejected yet again by them.” “sometimes I try to hide my true feelings from my family and my other friends, and I just hide away”	“my daughter refused to tell anyone what was wrong with her for many years…apart from close family. her friends, etc., probably guessed but never asked. As she got older she told a few people. their reactions varied. they usually promised to be there for her and texted her for a week or so after but then that was it. sometimes they told other people which broke her trust. I know many other sufferers who are very open about their illness so I guess that varies for years didn’t tell anyone, even when she had long stays as in-patient. now she is 17 and told a few people, but still dificult to be completely up front with people”	“telling even close friends how they really feel” “I have had a few patients who have felt very anxious about letting people know about their eating disorder - understandable- and I guess at least part of that is due to fear of possible rejection, so they end up saying “I’m fine” even to close friends even though they’re not if someone is unpleasant or they perceive to have been unpleasant, then they will tell me that they do not know what to say, or only later they will think of something to say, or they will take it out on themselves (self-harm).” “it might be helpful to explicitly provide them with the tools to deal with these situations, e.g., workshops on how to safely confront someone or how to discuss sensitive topics with your peers if you think they are angry with you - basically like survival skills sessions for sensitivity to rejection”