The Role of Social Rank in the Experience of an Anorexic Voice
Research type
Research Study
Full title
Exploring the Relevance of Social Rank Theory in Anorexia Nervosa and the Experience of an Anorexic ‘Voice’
IRAS ID
319919
Contact name
Joanna Mitchell
Contact email
Sponsor organisation
Research and Development Department
Duration of Study in the UK
1 years, 0 months, 1 days
Research summary
Research Summary
Research has found that a notable proportion of people with anorexia nervosa (AN) hear an inner anorexic ‘voice’ (AV) which may comment on their appearance, weight, and shape, and may tell them to behave in certain ways such as eating less food or exercising excessively. This AV is associated with negative outcomes, including more severe eating disorder symptoms. People with AN have also been identified to have lower perceived social rank (SR; their beliefs about their position in terms of power, attractiveness and fit with people around them) compared to the general population. In other populations, such as people with psychosis, low perceived social rank helps to explain why some people are more distressed by voices than others. It is not known why only some people with AN hear a voice, so this will be explored in our study. We are interested in whether an individuals perceived SR could help to explain the presence of an AV. We are also interested in whether someone’s perceived SR is related to the perceived power of their AV, and whether this leads to more severe eating disorder symptoms. If SR helps us to understand the AV experience, it could help to inform specific aspects of AV therapies and identify suitable candidates, perhaps reducing the duration and intensity of distress associated with hearing an AV. We will be recruiting adults with AN from Oxfordshire Eating Disorder Services and the general population. Eligibility will be determined by a cut-off score on a gold standard eating disorder symptom measure. We will compare AV hearers and non-hearers. Participants will be asked to complete online questionnaires assessing eating disorder, SR, and depression domains. They will be asked to repeat the eating disorder voice questionnaire one month later so that we can assess the stability of the AV experience.Summary of Results
Why were we interested in the “Anorexic Voice”?
• Most people with anorexia report hearing an inner “anorexic voice” (AV) that may comment on their body and their actions, such as telling them to restrict their intake.
• How individuals relate to this voice (e.g., find it helpful, neutral or threatening) impacts the severity of their eating disorder symptoms.
• We wanted to better understand the differences between people who report an AV and those who don’t.
Why were we interested in social rank?
• Social rank refers to the comparisons that people make between themselves and those around them, based on factors like appearance, abilities, and how they fit in with others.
• These comparisons lead us to rank ourselves as more or less superior than others and can influence our behaviours. For example, feeling inferior to others might make us more likely to submit to those around us.
• Social rank theory has been useful in understanding voice-hearing in people with psychosis:
o Individuals’ perceptions of social rank in relation to others are mirrored in their relationship with their voice(s). For example, if someone considers themselves inferior in social relationships, they are likely to feel inferior to their voice(s).
o Those who feel inferior to their voice(s) are more likely to experience distress from their voice(s) and may be more likely to comply with what their voice(s) tell them.
• We were interested in whether social rank theory can help us to better understand the AV, as it might help us to improve support for people with this experience (e.g., mental-health interventions).
What did we do?
• We recruited adults from the UK who reported having a diagnosis of Anorexia Nervosa or Atypical Anorexia Nervosa.
• Most of these people were recruited from the community (via social media) and some were recruited from the NHS.
• Participants were grouped based on whether they were currently (in the last week) experiencing an AV. There were 118 participants in the AV group and 58 participants in the non-AV group.
• All participants completed an online survey that included measures of social rank, the AV, and other mental health measures.
• Some participants agreed to complete one measure of the AV one month later, so we could find out if this experience changed over time.
What did we find?
• Individuals with an AV had similar perceptions of social rank as individuals without an AV: both groups had low perceptions of social rank on average.
• Individuals with an AV had more severe eating disorder symptoms than individuals without an AV.
• Within the AV group:
o Individuals who felt inferior in their social relationships (low social rank) also felt inferior in their relationship with their AV.
o Greater depressive symptoms and a more powerful AV significantly predicted more severe eating disorder symptoms, however social rank did not.
o The link between a powerful AV and eating disorder symptoms was not significantly affected by individuals’ social rank perceptions.
o 100% of individuals who reported an AV at the start of the study still reported it one month later. However, their appraisals of this relationship did change over time.
What are the real-world implications?
• Healthcare professionals may find it helpful to ask people with anorexia not only about whether they experience an AV but also how they relate to their AV.
• Healthcare professionals may also find it helpful to assess how individuals feel in relation to those around them as this can impact their eating disorder symptom severity and their relationship with the AV.
• This could help to identify individuals earlier who could benefit from support in their social relationships and their relationship with the AV.
What are the limitations of our study?
• We did not verify individuals’ diagnoses.
• We did not measure individuals' behaviours in response to the AV specifically e.g., whether they comply with it.
• We cannot confirm that voice power, social rank, and depressive symptoms cause more severe eating disorder symptoms.REC name
Wales REC 5
REC reference
23/WA/0118
Date of REC Opinion
27 Apr 2023
REC opinion
Favourable Opinion