Appearance-based rejection sensitivity as a mediator of the relationship between symptoms of social anxiety and disordered eating cognitions and behaviors

Eating Behaviors 27 (2017) 27–32

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Appearance-based rejection sensitivity as a mediator of the relationship between symptoms of social anxiety and disordered eating cognitions and behaviors

MARK

Jake Linardona,⁎, Rachel Braithwaiteb, Rachel Cousinsb, Leah Brennana,c a b c

School of Psychology, Australian Catholic University, 115 Victoria Parade, Locked Bag 4115, Melbourne, Victoria 3065, Australia School of Psychology, Counselling and Psychotherapy, Cairnmillar Institute, Camberwell, Victoria 3124, Australia Centre for Eating, Weight, and Body Image, Australia

A R T I C L E I N F O

A B S T R A C T

Keywords: Appearance-based rejection sensitivity Social anxiety Disordered eating Binge eating Vomiting Over-evaluation

Previous research has established a robust relationship between symptoms of social anxiety and disordered eating. However, the mechanisms that may underpin this relationship are unclear. Appearance-based rejection sensitivity (ABRS)—the tendency to anxiously expect and overreact to signs of appearance-based rejection—may be a crucial explanatory mechanism, as ABRS has been shown to maintain social anxiety symptoms and predict disordered eating. We therefore tested whether ABRS mediated the relationship between social anxiety symptoms and various indices of disordered eating (over-evaluation of weight/shape, restraint, binge eating, compulsive exercise, and vomiting). Data from community-based females (n = 299) and males (n = 87) were analyzed. ABRS was shown to mediate the relationship between social anxiety and the over-evaluation, restraint, binge eating, and compulsive exercise frequency, but not vomiting. These effects also occurred for both females and males separately. Findings demonstrated that ABRS may be an important mechanism explaining why socially anxious individuals report elevated symptoms of disordered eating. Future research testing all proposed mediating variables of the social anxiety-disordered eating link in a single, integrative model is required to identify the most influential mechanisms driving this relationship.

1. Introduction A consistent link has been reported between social anxiety symptoms and disordered eating. Studies have documented strong correlations between social anxiety symptoms and various indices of disordered eating (e.g., Hinrichsen, Waller, & Emanuelli, 2004). Symptoms of social anxiety are also common in eating disorders. For instance, Kaye, Bulik, Thornton, Barbarich, and Masters (2004) found that 20% of their sample of individuals with eating disorders (n = 672) exhibited clinically significant levels of social anxiety. Retrospective (e.g., Bulik, Sullivan, Fear, & Joyce, 1997), longitudinal (e.g., Buckner, Silgado, & Lewinsohn, 2010), and experimental research (e.g., Levinson & Rodebaugh, 2015) have shown social anxiety symptoms to precede and predict disordered eating onset, which suggests that social anxiety is a potentially important risk factor for disordered eating. An emerging body of literature has theorized how and why this link exists, with some studies having tested explanatory mechanisms of this relationship. Theoretically, the underlying psychopathology that maintains social anxiety and disordered eating is a pervasive concern

⁎

about how one appears to others (McLean, Miller, & Hope, 2007). Whereas cognitive models of disordered eating have proposed that a fear of negative evaluations (FNE) directed primarily toward shape and weight maintains disordered eating (Cooper, Wells, & Todd, 2004), cognitive models of social anxiety have proposed that a general FNE maintains social anxiety (Hofmann, 2007). Thus, both social anxiety and disordered eating symptoms share a fear of negative evaluations. However, research has also shown that the general (rather than weight and shape-based only) FNE proposed to maintain social anxiety symptoms could also maintain disordered eating, leading researchers to test general FNE as a possible mediating factor explaining the social anxiety-disordered eating link. For instance, FNE has been shown to correlate with both social anxiety symptoms and disordered eating (Gilbert & Meyer, 2005), and FNE, but not fear of positive evaluations, has mediated the relationship between social anxiety symptoms and disordered eating (Menatti, DeBoer, Weeks, & Heimberg, 2015; Menatti, Weeks, Levinson, & McGowan, 2013). Thus, Menatti et al. (2015) argued that FNE is not only an important variable that drives the social anxiety-disordered eating link, but FNE explained this relationship

Corresponding author at: Faculty of Health Sciences, Australian Catholic University, 115 Victoria Parade, Locked Bag 4115, Melbourne, Victoria 3065, Australia. E-mail address: [email protected] (J. Linardon).

http://dx.doi.org/10.1016/j.eatbeh.2017.10.003 Received 26 May 2017; Received in revised form 27 October 2017; Accepted 28 October 2017 Available online 31 October 2017 1471-0153/ © 2017 Elsevier Ltd. All rights reserved.

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to rejection magnify expectations of appearance-based rejection and vice versa (Park, 2007). ABRS and social anxiety have been shown to correlate, and researchers have conceptualized ABRS as an important maintaining factor for social anxiety (Park, 2007). It was argued that those high in ABRS are particularly sensitive to anxiety in social settings in fear of being negatively judged based on their appearance. Such individuals then come to fear, avoid, and withdraw from social settings, further perpetuating social anxiety symptoms (Park, 2007). ABRS may also increase the risk of disordered eating and associated concerns with weight and shape. Park (2007) argued that individuals high in ABRS associate physical flaws with rejection. Since a slender yet unattainable body type is considered ideal in modern society (Swami et al., 2010), these individuals become preoccupied with their weight and shape, are highly motivated to improve their appearance, and are therefore more likely to diet and exercise excessively (Park, 2007). Indeed, ABRS has been shown to predict body dissatisfaction, acceptance of cosmetic surgery, and disordered eating (e.g., Park, Calogero, Harwin, & DiRaddo, 2009). Critically, ABRS has mediated the relationship between social anxiety and body dysmorphic symptoms (BDD), suggesting that ABRS could be important in explaining why socially anxious individuals also exhibit elevated BDD symptoms (Lavell, Zimmer-Gembeck, Farrell, & Webb, 2014). Given the overlap between symptoms of BDD and disordered eating, it is also plausible that ABRS mediates the social anxiety-disordered eating relationship. This hypothesis, however, has not been tested. The aim of this study was to therefore test this hypothesis and build on the small body of literature that has examined mediators of the relationship between social anxiety symptoms and disordered eating. Analyzing data from 386 participants (299 females and 87 males), we aimed to test whether ABRS is mediator of the relationship between social anxiety and five distinct symptoms of disordered eating: the overevaluation of weight and shape, dietary restraint, binge eating, compulsive exercise, and vomiting.

because it centers around fearing events that elicit negative emotions known to precipitate disordered eating. Others have drawn from affect-regulation models (e.g., Fairburn, Cooper, & Shafran, 2003; Heatherton & Baumeister, 1991; Stice, Nemeroff, & Shaw, 1996) to test mechanisms of the social anxiety-disordered eating link, particularly as some have argued that disordered eating serves the function of regulating negative affect in socially anxious individuals (e.g., Wonderlich-Tierney & Vander Wal, 2010). Proponents of affect-regulation models have proposed that increases in negative affect trigger bulimic behavior and that bulimic behavior functions to alleviate negative affect, primarily because food or exercise is used for distraction or comfort (e.g., Stice et al., 1996). These bulimic behaviors become a conditioned response to negative affect that are negatively reinforced. Since negative affect, mood fluctuations, and feelings of anxiety are pervasive in socially anxious individuals (Hofmann, 2007), affect-regulation models are useful for conceptualizing the social anxiety-disordered eating link. Indeed, research that has used this framework has tested maladaptive emotion regulation strategies (McLean et al., 2007), shame (Grabhorn, Stenner, Stangier, & Kaufhold, 2006), social appearance anxiety (Levinson & Rodebaugh, 2012), and low self-acceptance (McClintock & Evans, 2001) as mediators, each of which have explained the social anxiety-disordered eating link. Although social anxiety symptoms are highly comorbid with disordered eating, are a barrier to help-seeking, and are predictive of poor disordered eating treatment outcomes, (Goodwin & Fitzgibbon, 2002), there has been little empirical work devoted to understanding why, or through what mechanisms, social anxiety leads to disordered eating. Fig. 1 provides an overview of mediators that have been tested. Due to consistent findings, maladaptive emotion regulation strategies and negative self-evaluative fears are plausible mechanisms driving this link. However, as Menatti et al. (2015) noted, more research is needed to pinpoint additional explanatory variables of the social anxiety-disordered eating relationship. They suggested this so that we can have a greater understanding of the factors implicated in this relationship, particularly since social anxiety and disordered eating are such broad constructs that encompass a variety of cognitive, behavioral, and emotional characteristics. Given that global negative evaluative fears are shown to be the most consistent mediating variable, this study intended on examining a specific component of negative evaluative fears—appearance-based rejection sensitivity (ABRS)—as another important mediating variable, with the intention of building on this small body of literature. ABRS refers to the tendency to anxiously expect, readily perceive, and overreact to signs of rejection based on physical appearance (Park, 2007). ABRS is composed of affective (anxious concerns) and cognitive (expecting rejection) components. Both components are proposed to interact with, and exacerbate each other, such that anxieties pertaining

2. Method 2.1. Participants There were 393 participants recruited for this study. The mean age in years of participants was 25.33 (SD = 8.19), and ages ranged between 18 and 69 years. There were 303 females and 90 males. Majority of participants lived in Australia (80%). Some participants reported living in the United States (8%), the United Kingdom (6.5%), and Asia (5.5%). Most participants were either married or partnered (49.1%) or single (49.4%).

Fig. 1. Variables tested as mediators of the relationship between symptoms of social anxiety and disordered eating. Note: 1 = Menatti (2015); 2 = Levinson (2012); 3 = Menatti (2013); 4 = Grabhorn (2006); 5 = McLean (2007); 6 = Wonderlich-Tierney (2010); 7 = McClintock (2001); shaded arrow = consistent mediating variable; unshaded arrow = mediating variable identified in one study; dotted arrow = variable inconsistently identified as mediator; bolded dot and arrow = variables that did not mediate the relationship; variable that correspond to each arrow are on the left.

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participants to indicate the number of times, over the past 28 days, they had exercised in a driven or compulsive way as a means to control their weight, shape or the amount of fat, or to burn off calories.

2.2. Measures 2.2.1. Predictor variable 2.2.1.1. Social anxiety. Social anxiety was assessed using the 24-item Liebowitz Social Anxiety Scale (LSAS; Liebowitz, 1987). The LSAS assesses fear and avoidance of social situations. Items are rated along a four-point scale, ranging from zero (none/never) to three (severe/ usually), and summed to produce a total score. Higher scores indicate greater levels of social anxiety. Reliability and construct validity has been established (Baker, Heinrichs, Kim, & Hofmann, 2002). The internal consistency for the LSAS was excellent in this study (α = 0.97).

2.2.3.5. Vomiting frequency. A single item from the EDE-Q was also used to assess vomiting frequency. This item asks participants to indicate the number of times, over the past 28 days, they had made themselves sick as a means to control weight or shape. 2.3. Procedure Ethics approval was obtained from the Cairnmillar Institute of Psychology Human Research Ethics Committee. An online questionnaire link was distributed through a variety of sources, including social networking websites (Facebook and Twitter) online forums (reddit, university forums), and personal contacts of the researchers. To be eligible to participate, participants were required to be over 18 years. There were no other exclusion criteria. After consent was obtained, participants completed the online questionnaire battery at a time and location of their convenience. The questionnaire battery took 20–30 min to complete. Participants did not receive reimbursement.

2.2.2. Mediator variable 2.2.2.1. Appearance-based rejection sensitivity. ABRS was assessed using the 15-item Appearance-Based Rejection Sensitivity Scale (Park, 2007). Each item describes a scenario in which an individual might anxiously expect to be rejected based on their appearance (e.g., “your significant other makes a comment about your weight”). Participants are asked to rate their anxiety about being rejected based on their appearance (e.g., “how anxious would you be that your significant other might be less attracted to you because of the way you look”) on a six point scale, ranging from one (very unconcerned) to six (very concerned), and their expectation (e.g., “I would expect my significant other to be less attracted to me because of the way I look”) on a six point scale ranging from one (very unlikely) to six (very likely). ABRS is calculated by multiplying the degree of anxious concern with the degree of rejection expectations in each situation, and then averaging across anxious expectation of rejection scores across situations for each participant. Higher scores indicate greater ABRS. Reliability and validity has been established (Park, 2007). The internal consistency for the ABRS was excellent in this study (α = 0.96).

2.4. Data analysis After computing basic descriptive statistics, mediation analyses were performed through the SPSS PROCESS macro. There were five mediation analyses, each examining whether ABRS mediated the relationship between social anxiety and the five disordered eating outcomes, while controlling for age. The five outcomes were over-evaluation, dietary restraint, binge eating, compulsive exercise, and vomiting frequency. Indirect effects and their statistical significance were tested using bootstrapping procedures (with 10,000 bootstrap samples). The indirect effect was considered statistically significant (p < 0.05) if the 95% bias-corrected confidence interval does not include zero. We then ran the same mediation analyses for female and male participants separately. Conclusions regarding the direction of these relationships cannot be made with cross-sectional data. Consistent with recommendations for conducting cross-sectional mediation analyses (Hayes & Rockwood, 2016), we then performed reverse mediation analyses to rule out possible alternative explanations for our hypothesized (and obtained) findings (e.g., that social anxiety mediates the ABRS-disordered eating relationship). Here, ABRS was entered as the predictor (instead of the mediator) and social anxiety as the mediator (instead of the predictor). Indirect effects were also calculated with 10,000 bootstrap samples.

2.2.3. Outcome variables 2.2.3.1. Over-evaluation of weight and shape. Shape and weight overevaluation was assessed using two items (i.e., “how often has your weight/shape influenced how you feel as a person”) from the Eating Disorder Examination Questionnaire (EDE-Q; Fairburn & Beglin, 1994). Both items are rated along a seven-point scale, ranging from zero (not at all) to six (markedly), and averaged to create a composite score, consistent with previous research (Goldschmidt et al., 2010; Hrabosky, Masheb, White, & Grilo, 2007; Linardon, 2016; Linardon & Mitchell, 2017). The distinctiveness of the over-evaluation factor from the shape and weight concerns factor and the body dissatisfaction factor has been reported in previous factor analytic research (Grilo et al., 2010; Grilo, Reas, Hopwood, & Crosby, 2015) and in a latent genetic and environmental risk factor twin study (Wade, Zhu, & Martin, 2011). Grilo, Reas et al. (2015) also reported excellent internal consistency for the over-evaluation factor (α = 0.91). Internal consistency for the over-evaluation factor was also excellent in this study (α = 0.94)

3. Results Outliers were initially screened. There were seven cases that exhibited large Mahalanobis values that exceeded the critical region χ2 (5) = 20.51, p < 0.001. These seven cases were deleted from the analyses, resulting in 386 participants. Residuals in regression models were centered on zero and did not deviate from a normal distribution.

2.2.3.2. Dietary restraint. Dietary restraint was assessed via the fiveitem restraint subscale from the EDE-Q. Each item (e.g., “have you been trying to limit the amount of food you eat to influence your weight or shape?”) is rated along a seven point scale, ranging from zero (no days) to six (every day), and then averaged. The internal consistency for this subscale was acceptable in the current study (α = 0.79).

3.1. Descriptive statistics Table 1 presents the descriptive statistics. Expectedly, the average scores obtained for these measures were below clinical cut-off scores (if available). For instance, for the LSAS, a score of 60 or greater is indicative of generalized social anxiety disorder (Rytwinski et al., 2009). While the mean LSAS for the current sample was lower than this cut-off, there was a moderate percentage (26%) of participants who scored above 60, which might indicate the presence of clinical cases in this sample. Further, a score of five or more on the over-evaluation composite is considered clinically significant for an eating disorder (Grilo, Ivezaj, and White, 2015). There was also a moderate percentage (23%)

2.2.3.3. Binge eating frequency. A single item from the EDE-Q was used to assess binge eating frequency. This item asks participants to indicate the number of times, over the past 28 days, they had eaten a large amount of food (given the circumstances) and felt a sense of loss of control. 2.2.3.4. Compulsive exercise frequency. A single item from the EDE-Q was used to assess compulsive exercise frequency. This item asks 29

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Table 1 Means, standard deviations, and correlations between study variables. Variable

1

2

3

4

5

6

7

1. Social anxiety 2. ABRS 3. Over-evaluation weight/shape 4. Dietary restraint 5. Binge eating frequency 6. Compulsive exercise frequency 7. Vomit frequency Mean Standard deviation Min–Max

0.55⁎⁎⁎ 0.34⁎⁎⁎ 0.22⁎⁎⁎ 0.15⁎⁎ 0.11⁎ 0.13⁎ 50.88 30.32 0–134

0.62⁎⁎⁎ 0.39⁎⁎⁎ 0.27⁎⁎⁎ 0.15⁎⁎ 0.13⁎ 15.11 8.37 1.07–35.60

0.45⁎⁎⁎ 0.27⁎⁎⁎ 0.26⁎⁎⁎ 0.13⁎⁎ 2.77 2.15 0–6

0.21⁎⁎⁎ 0.37⁎⁎⁎ 0.16⁎⁎ 1.78 1.50 0–6

0.21⁎⁎⁎ 0.26⁎⁎⁎ 2.01 3.96 0–20

0.21⁎⁎⁎ 3.03 6.15 0–30

0.26 1.51 0–17

Note:

⁎⁎⁎

= p < 0.001;

⁎⁎

= p < 0.01; ⁎ = p < 0.05; ABRS = appearance-based rejection sensitivity.

3.3. Reverse mediation analyses

of participants who scored above this cut-off, although the mean overevaluation score was much lower than five. Finally, the diagnostic classification for bulimia nervosa and/or binge eating disorder requires the presence of binge eating and/or purging at least once a week over the past three months (American Psychiatric Association, 2013). The average frequencies of these behaviors fell below this diagnostic threshold in this sample. For the correlations, social anxiety and ABSR were significantly and positively related to the over-evaluation of weight and shape, dietary restraint, binge eating, compulsive exercise and vomiting frequency.

We then performed reverse mediation analyses, where ABRS was entered as the predictor and social anxiety as the mediator. The indirect effects of ABRS on over-evaluation (β = 0.001, 95% CI = −0.05, 0.06), dietary restraint (β = 0.001, 95% CI = − 0.06, 0.06), binge eating (β = 0.001, 95% CI = − 0.07, 0.06), and compulsive exercise (β = 0.02, 95% CI = − 0.04, 0.08) via social anxiety were non-significant. 4. Discussion

3.2. Mediation analyses The current study aimed to test whether ABRS is a mediator of the relationship between symptoms of social anxiety and disordered eating. Results demonstrated that ABRS significantly mediated the relationship between social anxiety symptoms and four of the five disordered eating outcomes: over-evaluation, dietary restraint, binge eating, and compulsive exercise. These mediation effects occurred for both female and male participants, although mediation was not observed specifically for males and females when compulsive exercise was the outcome. These findings provide the preliminary and necessary (but not sufficient) support for the idea that the tendency to anxiously expect and overreact to signs of appearance-based rejection could be an important mechanism explaining why socially anxious individuals exhibit elevated levels of disordered eating. Moreover, the present findings were largely consistent with previous cross-sectional research demonstrating that the social anxiety-disordered eating relationship is explained by negative affective-related factors (e.g., poor emotion regulation; McLean et al., 2007). Since affect-regulation models have proposed that disordered eating behaviors function to regulate negative affect, it may seem that this framework cannot account for the fact that we observed mediation for cognitive outcomes (over-evaluation and dietary restraint). However,

Five mediation analyses were conducted. After controlling for social anxiety and age in Step 1, ABRS significantly and uniquely predicted the over-evaluation of weight and shape, dietary restraint, binge eating, and compulsive exercise, but did not significantly predict vomiting. Table 2 presents the beta weights for age, social anxiety and ABRS, and the amount of additional variance ABRS accounted for. Table 3 presents the indirect and direct effects from the mediation analyses. As seen, with the exception of vomiting frequency, all indirect effects were statistically significant, suggesting that ABRS mediated the relationship between social anxiety symptoms and (a) over-evaluation, (b) dietary restraint, (c) binge eating, and (d) compulsive exercise. None of the direct effects (predicting disordered eating from social anxiety while controlling for ABRS and age) were statistically significant. These mediation effects were then tested separately for females and males (controlling for age). As seen (Table 3), for both females and males, ABRS was shown to mediate the relationship social anxiety symptoms and (a) over-evaluation, (b) dietary restraint, (c) binge eating. The indirect effects for the social anxiety-compulsive exercise relationship and the social anxiety-vomiting relationship were not statistically significant for males or females.

Table 2 Results of the mediation analyses regressing disordered eating symptoms on social anxiety and ABRS for the entire sample. Predictor

Over-evaluation B (SE)

Step 1 Age SA Step 2 Age SA ABRS

Dietary restraint β

B (SE)

Binge eating β

B (SE)

Compulsive exercise β

B (SE)

β

Vomiting B (SE)

β

− 0.01 (0.01) − 0.05 0.02 (0.00) 0.34⁎⁎⁎ 2 R = 0.12, F (2, 384) = 26.20⁎⁎⁎

0.01 (0.01) 0.05 0.01 (0.02) 0.22⁎⁎⁎ 2 R = 0.05, F(2384) = 10.17⁎⁎⁎

0.04 (0.03) 0.08 0.02 (0.01) 0.15⁎⁎ 2 R = 0.03, F(2384) = 5.62⁎⁎

− 0.07 (0.04) −0.08 0.02 (0.01) 0.11⁎ 2 R = 0.02, F(2384) = 3.82⁎

−0.01 (0.01) − 06 0.01 (0.01) 0.13⁎ 2 R = 0.02, F(1, 384) = 3.88⁎

− 0.02 (0.01) − 0.08⁎ 0.00 (0.00) 0.01 0.16 (0.01) 0.62⁎⁎⁎ 2 ΔR = 0.27, ΔF(1383) = 169.98⁎⁎⁎

0.01 (0.01) 0.03 0.00 (0.00) 0.01 0.07 (0.01) 0.39⁎⁎⁎ 2 ΔR = 0.10, ΔF(1383) = 46.96⁎⁎⁎

0.04 (0.03) 0.07 0.00 (0.08) 0.00 0.13 (0.03) 0.27⁎⁎⁎ 2 Δ R = 0.05, ΔF(1383) = 20.08⁎⁎⁎

− 0.07 (0.04) −0.09 0.01 (0.01) 0.04 0.10 (0.04) 0.13* 2 ΔR = 0.01, Δ F(1383) = 5.16⁎

−0.01 (0.01) − 0.06 0.00 (0.01) 0.06 0.02 (0.01) 0.08 2 ΔR = 0.01, ΔF(2383) = 2.09

Note: ΔR2 = R2 change from step 1 to step 2; ΔF = F change from step 1 to step 2; rejection sensitivity.

⁎⁎⁎

= p < 0.001;

30

⁎⁎

= p < 0.01; ⁎ = p < 0.05; SA = social anxiety; ABRS = appearance-based

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Table 3 Mediation analyses presented for the entire sample and then by sex. Indirect path Entire sample (n = 386) Social anxiety → ABRS → Over-evaluation Social anxiety → ABRS → Dietary restraint Social anxiety → ABRS → Binge eating Social anxiety → ABRS → Compulsive exercise Social anxiety → ABRS → Vomiting Females only (n = 299) Social anxiety → ABRS → Over-evaluation Social anxiety → ABRS → Dietary restraint Social anxiety → ABRS → Binge eating Social anxiety → ABRS → Compulsive exercise Social anxiety → ABRS → Vomiting Males only (n = 87) Social anxiety → ABRS → Over-evaluation Social anxiety → ABRS → Dietary restraint Social anxiety → ABRS → Binge eating Social anxiety → ABRS → Compulsive exercise Social anxiety → ABRS → Vomiting

Indirect effect (95% CI)

Direct effect (95% CI)

0.34 (0.27, 0.41) 0.21 (0.15, 0.28) 0.15 (0.09, 0.21) 0.07 (0.01, 0.14) 0.05 (− 0.01, 0.09)

0.00 0.00 0.00 0.01 0.00

(− 0.01, (− 0.01, (− 0.01, (− 0.02, (− 0.00,

0.01) 0.01) 0.01) 0.03) 0.01)

0.34 (0.26, 0.41) 0.18 (0.12, 0.26) 0.11 (0.06, 0.18) 0.06 (− 0.00, 0.14) 0.04 (− 0.02, 0.08)

0.01 0.01 0.01 0.01 0.01

(− 0.00, (− 0.00, (− 0.02, (− 0.01, (− 0.00,

0.01) 0.01) 0.02) 0.04) 0.01)

0.34 (0.19, 0.53) 0.30 (0.14, 0.53) 0.29 (0.13, 0.50) 0.15 (− 0.01, 0.34) 0.13 (− 0.05, 0.23)

−01 (− 0.02, 0.01) −0.00 (−0.01, 0.01) −0.01 (−0.04, 0.01) −0.01 (−0.08, 0.06) −0.00 (−0.01, 0.01)

Note: Bold indicates statistical significance (p < 0.05); ABRS = appearance-based rejection sensitivity; Effects presented are standardized coefficients.

longitudinal research examining the effect of ABRS on disordered eating over time. Second, disordered eating behaviors were assessed through single items. Individual items may not capture the full complexity of these behaviors, such as underlying cognitive (loss of control) and affective components (extreme guilt) that accompany bulimic symptoms. Thus, using validated measures that capture these underlying components of disordered eating may allow for a more rigorous investigation of the role of ABRS on disordered eating. Fourth, we did not measure constructs closely related to ABRS (appearance anxiety, rejection sensitivity), so we were not able to determine whether ABRS merely represents shared variance with these constructs. Finally, we did not apply a Bonferroni correction to protect against type 1 error, so the findings should be interpreted with this limitation. However, this correction would only lead to adjustments to the p-value, not the effect size or coefficients. It is argued that the effect sizes and coefficients are most important for determining whether a construct may have practical significance for further study (Garamszegi, 2006). In conclusion, this was the first study to test the mediating role of ABRS on social anxiety symptoms and disordered eating. Findings demonstrated that ABRS may be an important mechanism explaining why socially anxious individuals exhibited elevated levels of disordered eating. Additional research incorporating all of the proposed mediators of this relationship into a single, integrative model is needed to identify the most robust explanatory mechanisms of the social anxiety-disordered eating relationship.

Striegel-Moore, Silberstein, and Rodin (1993) proposed that an individual's preoccupation with weight, shape and dieting also reflects an underlying attempt to attenuate interpersonal anxieties by projecting a positive self-presentation. Consequently, in socially anxious individuals, the over-evaluation of weight and shape and dietary restraint might be used to project a positive self-image and lessen anxious expectations and concerns about appearance-based rejection. In addition to the present findings, previous cross-sectional studies have also identified mediators of the relationship between social anxiety and disordered eating (e.g., Grabhorn et al., 2006). Although pinpointing single mediators is important for informing future longitudinal work on the kinds of variables that require investigation as causal mechanisms, further cross-sectional research seeking to understand the social anxiety-disordered eating relationship is also needed. In particular, it would be beneficial to test all of the identified statistical mediators into a single, integrative model, as it would allow researchers to identify (a) which mediators explain this relationship over and above the other mediators included, and (b) which mediators are redundant because of their overlap with other, more robust mediators. For example, once Menatti et al. (2015) included FNE in their mediation model of social anxiety and body dissatisfaction, the previous mediating effect of fear of positive evaluations on this relationship (in a single mediation model) became statistically non-significant. The authors argued that because fear of positive evaluations and FNEs correlated highly (r = 0.59), and because FNE was a stronger predictor of body dissatisfaction than fear of positive evaluations, fear of positive evaluations effect merely represented overlapping variance with FNE, hence making it less important in this relationship. Thus, future research testing all proposed mediators in a single model might allow us to better conceptualize the crucial factors driving the relationship between social anxiety and disordered eating. ABRS did not mediate the link between social anxiety and vomiting. This finding must be interpreted with caution. The variability of selfreported vomiting was low in our sample. The mean vomiting frequency was 0.26 (SD = 1.51), and 91% of the sample reported that they had not self-induced vomited over the past month. Thus, the lack of mediation effect observed is possibly a result of the restricted range of scores on this outcome. Future research should test this relationship in a clinical sample that frequently engages in self-induced vomiting. There are limitations to this study that need to be considered. The cross-sectional design precluded causality inferences. Experimental and longitudinal research is needed for causal claims. However, cross-sectional research is an important first-step for identifying disordered eating risk factors, and this study will serve as an impetus for

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