A mixed-methods approach to conceptualizing friendships in anorexia nervosa

Background Individuals with anorexia nervosa have reported feelings of loneliness, social anhedonia, and interpersonal difficulties. This study sought to clarify the nature of interpersonal relationships in adults with anorexia, which may help improve existing interventions while also facilitating the attainment of something that might compete with the drive for thinness: friendships. Methods The present study used a mixed-methods approach to investigate friendship experiences in three groups: anorexia (n = 27), participants with a history of anorexia who are weight restored (n = 20), and healthy controls (n = 24). Thematic analysis was used to isolate the most prevalent themes that emerged from an open-ended interview of experiencing friendships in a subset of participants. Three self-report questionnaires investigating friendship valuation and attachment styles were also administered. Results 11 unique themes emerged in the data: social comparison, reciprocity, trust, fear of negative evaluation, perceived skills deficit, logistical barriers, reliability, identity issue, low interest, similarity, and conflict avoidance. Only 17% of those with anorexia reported experiencing friendships as positive, relative to 82% of healthy controls and 52% of weight restored participants. Lastly, on self-report measures, participants with anorexia reported greater reliance on themselves versus others, greater use of care-seeking behaviors, and more fear/anger at the thought of losing an attachment figure (p < .05 in all cases). Conclusion Results suggest that individuals with anorexia have particular challenges which interfere with the formation and maintenance of friendships, such as viewing friendships negatively and struggling with social comparisons in friendships. Assessing and addressing barriers to intimacy may motivate those with anorexia to relinquish dangerous symptoms that maintain the illness.