American Journal of Psychiatry and Neuroscience

2017; 5(4): 40-44

http://www.sciencepublishinggroup.com/j/ajpn
doi: 10.11648/j.ajpn.20170504.11
ISSN: 2330-4243 (Print); ISSN: 2330-426X (Online)

Role of Anxiety, Depression and Anger in Eating Disorders-

Structural Model
Seyyed Mohammad Moosavi1, Fatemeh Amini2, *
1
Department of Psychiatry, Mazandaran University of Medical Sciences, Sari, Iran
2
Department of Psychology, Islamic Azad University of Sari, Sari, Iran

Email address:
[email protected] (F. Amini)
*
Corresponding author

To cite this article:

Seyyed Mohammad Moosavi, Fatemeh Amini. Role of Anxiety, Depression and Anger in Eating Disorders- Structural Model. American
Journal of Psychiatry and Neuroscience. Vol. 5, No. 4, 2017, pp. 40-44. doi: 10.11648/j.ajpn.20170504.11

Received: June 18, 2017; Accepted: July 19, 2017; Published: August 14, 2017

Abstract: Aim of current study was to offer structural model regarding role of anxiety, depression and anger in eating
disorder. Noting morbidity and mushrooming trend of eating disorder in clinical settings and its antagonistic features among
afflicted individuals, with respect to clinical implication and, theoretical dimensions, conducting current study seemed vital.
Materials and Methods: This study was descriptive-correlational study. Statistical society of current study, consisted of 750
individuals with BMI ≥ 25, who were admitted to nutrition clinic at Sari General Hospital (Sari, Iran). Sample size was
specified as 226 according to Krejcie and Morgan Table. We used DASS-20 with respect to depression, anxiety and stress
assessment; Spielberger’s State-Trait Anger Expression Inventory in clinical patients with respect to anger assessment, EDDS
(Eating disorder diagnostic scale) regarding assessment of eating disorders (anorexia nervosa, bulimia nervosa and binge
eating disorder). With respect to data analyze, SPSS-22 and structural equation modeling and regression model via Lisrel test
were used. Results: According to results of current study, anxiety, depression and aggression maintain positive and influential
roles with respect to anorexia nervosa, bulimia nervosa and binge eating disorder.
Keywords: Anxiety, Depression, Aggression, Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder

to diagnose and treat eating disorders, reviews of medical

1. Introduction education frequently show a lack of adequate training in their
Eating disorders, which are associated with a host of identification and treatment, and hence health care
adverse medical morbidities, negative psychological professionals may only detect an eating disorder once
sequelae, and considerable reductions in quality of life, substantial medical and psychological consequences have
should be diagnosed and treated promptly. However, primary developed. [4, 5] Eating disorders are an important cause of
care physicians may find it uniquely challenging to detect physical and psychosocial morbidity in adolescent girls and
eating disorders in their early stages, before obvious physical young adult women. They are much less frequent in men.
problems arise and while psychological symptoms are subtle. Eating disorders are divided into three diagnostic categories:
Although psychological symptoms may dominate the anorexia nervosa, bulimia nervosa, and the atypical eating
presentation, the physician is an integral member of the disorders. However, the disorders have many features in
treatment team and is in a unique role to diagnose and treat common and patients frequently move between them, so for
eating disorders [1]. the purposes of this Seminar we have adopted a
Health service utilization among adults with eating transdiagnostic perspective. The cause of eating disorders is
disorders is high, and hospitalization expenses are on the rise complex and badly understood. There is a genetic
[2]. Among adults with eating disorders, at least half had predisposition, and certain specific environmental risk factors
their disorder first diagnosed by their primary care physicians have been implicated. Research into treatment has focused on
[3, 4]. Although primary care physicians are in a unique role bulimia nervosa, and evidence-based management of this
disorder is possible. A specific form of cognitive behaviour
41 Seyyed Mohammad Moosavi and Fatemeh Amini: Role of Anxiety, Depression and Anger in
Eating Disorders- Structural Model

therapy is the most effective treatment, although few patients nonpurging type, which is characterized by excessive
seem to receive it in practice. Treatment of anorexia nervosa exercise, fasting, or strict diets. 5 As with AN, patients with
and atypical eating disorders has received remarkably little BN may place undue emphasis on their body shape and live
research attention [6]. in fear of gaining weight [10]. Currently, if binge eating and
(1) Anorexia Nervosa (AN) purging occur in the context of low weight and amenorrhea,
The prevalence of AN is approximately 0.5% to 1% and is AN is diagnosed. Although crossover from AN to BN is
highest among adolescent girls and young women. Anorexia common, crossover from BN to AN is relatively rare unless
nervosa is characterized by an abnormally low body weight the patient was originally diagnosed as having AN [17-19].
(at least 15% below what would be expected), a (3) BINGE-EATING DISORDER
corresponding fear of weight gain, and an undue emphasis on Binge-eating disorder is characterized by the
weight and shape in self-evaluation [7]. Although consumption of large amounts of food in a 2-hour time
amenorrhea (ie, loss of 3 consecutive menstrual cycles) is period, accompanied by a perceived loss of control. 5
currently required for the diagnosis, the importance of this Additional symptoms include feeling uncomfortably full,
symptom is unclear, and as such, the eating disorders eating rapidly, eating alone, eating when not hungry, and
workgroup of the Diagnostic and Statistical Manual of feeling disgusted afterward [17-19] Unlike BN,
Mental Disorders (DSM) (Fifth Edition) has strongly compensatory behavior (eg, vomiting, laxative abuse) does
considered removing it as a criterion for AN [8] Anorexia not accompany these binge episodes. 5 When diagnosing
nervosa can be classified into 2 subtypes: the restricting BED, the clinician should take care to differentiate it from
subtype and the binge-eating/purging subtype. Patients with overeating. Overeating episodes often occur at social
AN who rarely binge-eat or purge but maintain a fairly functions, where abundant food is readily available, the
regular pattern of caloric restriction may be classified as mood is relaxed or positive, and other people are also
having the restricting subtype, whereas those who regularly overeating, whereas binge episodes typically are secretive
engage in binge eating and/or compensatory behavior to and occur in the context of negative mood and all-or-
prevent weight gain will be diagnosed as having the binge- nothing thinking. Primary care physicians may elect to
eating/purging subtype [7]. Many of those with the restricting screen for BED using the Eating Attitudes Test, the most
subtype will eventually develop binge eating, with at least widely used eating disorder screening tool [8-10].
one-third of patients crossing over into BN [13]. Crossover to Alternatively, the Eating Disorder Diagnostic Scale is a 22-
binge eating and BN typically occurs within the first 5 years item, self-report inventory created to diagnose AN, BN, and
of the illness [13]. Women with AN who develop BN are BED in accordance with DSM-IV criteria. 8 However, the
likely to relapse back into AN [13]. Questionnaire on Eating and Weight Patterns-Revised,
The outcomes associated with AN are poor, with only a which generates diagnostic information regarding BED, in
35% to 85% recovery rate and a protracted recovery, ranging addition to information regarding dieting and weight
from 57 to 79 month [14]. Not only can AN evolve into a history, has been widely used with diverse community and
chronic condition, it is one of the most medically serious clinical samples, including severely obese candidates for
psychiatric disorders [15, 16] People with AN are affected by bariatric surgery [10-13-19].
the physical consequences of the severe weight loss, along All in all, in current study we aimed to define the role of
with psychological comorbid conditions that contribute to depression, anxiety and aggression in Eating disorders via
mortality, [17] with suicides representing a large portion of structural model approach. We would discuss the main eating
the deaths from AN. [18] Depression, a consequence of poor disorders seen in primary care, including anorexia nervosa
caloric intake and low weight, is frequently comorbid with (AN), bulimia nervosa (BN), binge-eating disorder (BED).
AN and often resolves with re-feeding [16] Anxiety
symptoms are common and often precede the development of 2. Materials and Methods
the illness [19].
(2) BULIMIA NERVOSA This study was descriptive-correlational study. Statistical
The clinician will encounter patients with BN more often society of current study, consisted of 750 individuals with
than those with AN, because BN has a higher prevalence BMI ≥ 25, who were admitted to nutrition clinical at Sari
among women (1.0%-1.5%). However, often secretive and General Hospital (Sari, Iran). Sample size was specified as
lacking obvious physical stigmata such as emaciation, 226 according to Krejcie and Morgan Table. We used DASS-
patients with BN may avoid detection, with only a minority 20 with respect to depression, anxiety and stress assessment;
seeking treatment (12-17) The modal patient is a woman Spielberger’s State-Trait Anger Expression Inventory in
aged 16 to 22 years; however, the physician may encounter clinical patients with respect to anger assessment, EDDS
BN in older patients. Bulimia nervosa can be classified into 2 (Eating disorder diagnostic scale) regarding assessment of
subtypes: the purging type, which is characterized by eating disorders (anorexia nervosa, bulimia nervosa and
episodes of binge-eating (an inordinately large amount of binge eating disorder). With respect to data analyze, SPSS-22
food, in a short period of time, in an out-of-control fashion), and structural equation modeling and regression model via
followed by compensatory behavior, such as self-induced Lisrel test were used.
vomiting, laxative abuse, and diuretic abuse; and the (1) DASS
 American Journal of Psychiatry and Neuroscience 2017; 5(4): 40-44 42

DASS, the Depression Anxiety Stress Scales, [20] is made eating disorder module of the Structured Clinical Interview
up of 42 self-report items to be completed over five to ten for DSM-IV (SCID)16 [22]. In follow up studies of the
minutes, each reflecting a negative emotional symptom [21], reliability and validity of the EDDS it was shown to be
Each of these is rated on a four-point Likert scale of sufficiently sensitive to detect the effects of eating disorders
frequency or severity of the participants' experiences over the prevention programs, response to such programs and the
last week with the intention of emphasizing states over traits. future onset of eating disorder pathology and depression. The
These scores ranged from 0, meaning that the client believed EDDS shows both full and sub threshold diagnoses for
the item "did not apply to them at all", to 3 meaning that the anorexia nervosa, bulimia nervosa and binge eating disorder.
client considered the item to "apply to them very much, or EDDS is a continuous eating disorder symptom composite
most of the time". It is also stressed in the instructions that score [23]. The PhenX Toolkit uses the EDDS for as an
there are no right or wrong answers. The sum of the relevant Eating Disorders Screener protocol [24].
14 items for each scale constitute the participants' scores for
each of Depression, Anxiety and Stress, [21] including items 3. Results
such as "I couldn't seem to experience any positive feeling at
all", "I was aware of the dryness of my mouth" and "I found According to results of current study, as predicted anxiety,
it hard to wind down" in the respective order of the scales. depression, anger, maintain decisive role regarding
The order of the 42 items has been randomized so that items pathogenesis of Anorexia Nervosa.
of the same scale are not clustered together. Each of the
scales is then broken down into subscales comprising two to
five items each.
The Depression scale has subscales assessing dysphoria,
hopelessness, devaluation of life, self-deprecation, lack of
interest/involvement, anhedonia and inertia.
The Anxiety scale assesses autonomic arousal, skeletal
muscle effects, situational anxiety and subjective experience
of anxious affect.
The Stress scale's subscales highlight levels of non-chronic Figure 1. Analyzing Dynamic of Anger, Anxiety and Depression with Respect
to Anorexia Nervosa.
arousal through difficulty relaxing, nervous arousal and being
easily upset/agitated, irritable/over-reactive and impatient
Figure 1, delineates dynamic and valence of Anger,
[20].
Anxiety and Depression with respect to pathogenesis of AN.
(2) State-Trait Anger Expression Inventory-
With respect to results of current study, as predicted
The State-Trait Anger Expression Inventory-2 (STAXI-2)
anxiety, depression, anger, maintain decisive role regarding
assesses various areas of anger and the traits of experiencing
pathogenesis of Bulimia Nervosa.
anger. A common use for the STAXI is to collect information
for people with anger issues and for creating treatment plans.
Participants are asked to respond to 57 items using a 4-point
scale (“Not at all” to “Almost Always”). Approximately 12
to 15 minutes is required for completion. STAXI is the
revised edition which had only included 44-items. The State-
Trait Anger Expression Inventory is a well-known instrument
and it has supported data for relatively high reliability and
validity. In the authors test manuals, the psychometric
properties included high alpha coefficients for internal Figure 2. Analyzing Dynamic of Anxiety, Depression and Anger with
reliability for all subscales except for the Trait Anger Respect to Bulimia Nervosa.
Scale/Angry Reaction (0.73-0.76). There is extensive
showing of validity for the original versions of STAXI but
none for the current edition. Concurrent validity of the
original STAXI is strongly presented with correlations with
the Multiphasic Inventory (Hostility and Over Hostility
Scales), Buss-Durkee Hostility Inventory, and the Eysenck
Questionnaire (Psychoticism and Neuroticism).
(3) The Eating Disorder Diagnostic Scale
(EDDS) is a 22 item self-report questionnaire that assesses
Figure 3. Analyzing Dynamic of Anxiety, Depression and Anger with respect
the presence of three eating disorders; anorexia nervosa, to Binge Eating Disorder.
bulimia nervosa and binge eating disorder. It was adapted by
Stice et al. in 2000 from the validated structured psychiatric Figure 2, delineates dynamic and valence of Anger,
interview: The Eating Disorder Examination (EDE) and the Anxiety and Depression with respect to pathogenesis of AN.
43 Seyyed Mohammad Moosavi and Fatemeh Amini: Role of Anxiety, Depression and Anger in
Eating Disorders- Structural Model

According to results of current study, as predicted anxiety,

depression, anger, maintain decisive role regarding
pathogenesis of BN.
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