Experiences of shame and guilt in anorexia and bulimia nervosa: a systematic review

Objectives

Emotional states may play an important role in the development and maintenance of anorexia (AN) and bulimia nervosa (BN). This systematic review aimed to examine the evidence regarding the relationship that shame and guilt have with two eating disorders, AN and BN.

Methods

Four major databases (Pubmed, PsychINFO, Web of Science, Medline) were searched (up until April 2018) for studies measuring guilt or shame in clinically diagnosed AN and BN groups. Included papers were evaluated for risk of bias.

Results

Twenty-four papers met the inclusion criteria. Several methodological issues were noted within the reviewed studies, including a lack of longitudinal data and unaccounted confounding variables. Nonetheless, shame was typically more common in those with AN and BN than controls, was positively related to the severity of symptoms, and associated with the onset of eating disorder-related difficulties (e.g., binging or purging). Effect sizes were typically moderate to large. The role of guilt was less clear, with few studies and mixed results.

Discussion

There is preliminary evidence that shame is implicated in the aetiology of AN and BN presentations, whilst there is currently insufficient evidence of such a role for guilt. It remains unclear whether shame is a risk factor for the development of AN and BN or a consequence of these difficulties.

Practitioner Points

Elevated shame appears to be a feature of anorexia (AN) and bulimia nervosa (BN).

Shame appears to fluctuate with the occurrence of eating disordered behaviours like binging, purging or restricted eating.

Guilt is less consistently linked to AN and BN presentations.

Interventions directed at shame may be helpful for these populations.

A lack of longitudinal data means the temporal features of these relationships are still unclear.