REGULAR ARTICLE

Altered Social Hedonic Processing in Eating Disorders

Kate Tchanturia, PhD1* ABSTRACT

Objective: Exploring social anhedonia
Helen Davies, PhD1 in eating disorders (ED) was the main
Amy Harrison, PhD1 objective of this study. Social anhedonia
John R.E. Fox, PhD2 relates to a reduced feeling of pleasure
Janet Treasure, MD, PhD1 from social stimulation. Researching the
exact nature of problems in interpersonal
Ulrike Schmidt, MD, PhD1 relationships is an important topic for
clinicians and researchers in the field.
Method: The revised social anhedonia
scale was completed by 148 participants:
than people without ED. Recovered AN
had an intermediate profile in between
AN and HC. Clinical severity and alexithy-
mia were strongly associated with social
anhedonia scores.
Discussion: Difficulty identifying and
expressing feelings could be related to
this diminished drive for social pleasure.
Tackling these interpersonal maintaining
factors in treatment is likely to be a
worthwhile endeavor. V C 2012 by Wiley

anorexia nervosa (AN) n 5 72; bulimia Periodicals, Inc.

nervosa (BN) n 5 19; recovered AN n 5
14; healthy controls (HC) n 5 43. Partici- Keywords: social anhedonia; anorexia;
pants also completed mood related meas- bulimia; recovered
ures and the Toronto Alexythimia scale.
(Int J Eat Disord 2012; 00:000–000)
Results: People with AN and BN had
higher self-reported social anhedonia

Introduction Anhedonia can be defined as a loss of interest in

It is recognized that anorexia nervosa (AN) is a dis-
order which has core emotional disturbances1–5
and it has been hypothesized that the development
and maintenance of eating disorders (EDs), like
AN, may be associated with a dysregulated reward
system.6 For example, people with AN, relative to
healthy controls (HC), demonstrate low levels of
physiological responding to positive (reward) stim-
uli and poor learning from past experiences, as well
as generally low levels of physiological responses
when skin conductance measures are combined
with a behavioral task of decision making.7 We fur-
ther understand that people with EDs show
reduced pleasure for a range of stimuli, such as
from food,8 amusing stimuli,9 and a reduced desire
for sexual activity.10
Accepted 1 May 2012
Supported by NIHR Biomedical Research Centre for Mental
Health at South London; Maudsley NHS Foundation Trust; Institute
of Psychiatry, King’s College London; Swiss Anorexia Foundation.
*Correspondence to: Dr. Kate Tchanturia, PO59, King’s College
London, Institute of Psychiatry, Department of Psychological
Medicine, De Crespigny Park, London SE5 8AF, UK.
E-mail: kate.tchanturia@kcl.ac.uk
1 potential effects of starvation on the reward sys-
Section of Eating Disorders, King’s College London, Institute of
Psychiatry, Psychological Medicine, London, United Kingdom
2
Division of Clinical Psychology, University of Manchester,
Manchester, United Kingdom
Published online in Wiley Online Library
(wileyonlinelibrary.com). DOI: 10.1002/eat.22032
VC 2012 Wiley Periodicals, Inc.
activities in most or all activities and is associated
with low motivation to engage in pleasurable
events, therefore invoking the involvement of neu-
ral pathways related to seeking out and obtaining
rewards.11 Anhedonia is part of the clinical presen-
tation of depression, which is the most commonly
comorbid disorder in people with EDs12,13 with
59% of people with EDs experiencing one or more
episode of major depressive disorder.14 Socially,
people with EDs, particularly AN, are observed to
be shy, have limited social networks, and self-
report poorer quality and quantity of relationships
with their family, friends, and colleagues.15–17
Therefore, it is possible that people with EDs may
be more likely than HCs to have high levels of
social anhedonia, which relates to a reduced feeling
of pleasure from social stimulation and a reduced
drive to seek out social interaction. However, de-
spite the presence of interpersonal difficulties pro-
posed to maintain the disorder,1 few studies have
explored whether individuals with EDs find social
interaction less pleasurable than the healthy popu-
lation.
Evidence exists, however, that highlights the
tem individuals would usually gain from social
contact. Keys et al.18 observed participants whose
diet was deliberately halved over a period of 24
weeks and found these individuals showed
increased social withdrawal, reduced libido, and

International Journal of Eating Disorders 00:0 000–000 2012 1

TCHANTURIA ET AL.
they sought out social contact less frequently,
resulting in higher rates of social isolation within
the group. It is possible that the increased rates
of depression reported in these individuals dur-
ing the semistarvation phase might have contrib-
uted to their reduced ability to derive pleasure
from social contact. Given that symptoms of
depression may persist despite successful recov-
ery from the ED,19 it is possible that untreated
social anhedonic symptoms persist even after the
disorder has remitted, perhaps limiting the indi-
vidual’s quality of life and accounting for the
persistently small social networks observed de-
spite recovery.16 As higher rates of residual symp-
toms at discharge predict relapse,20 exploring
social anhedonia further in people with EDs
might offer opportunities to improve quality of
life and increase the likelihood of successful
long-term recovery from the illness.
There are three established ways to explore social
anhedonia: interview-based instruments, labora-
tory-based experiments, and self-report question-
naires.21 Interview-based methods are absent in
the literature on EDs. There are a limited number
of studies which have used an experimental design
in EDs, with each study employing a different para-
digm. For example, using the startle-reflex para-
digm, Friederich et al.22 report that people with
EDs show aversive responses to appetitive stimuli.
Studies exploring facial expressions using either
observed9 or unobserved (electromyography)23
techniques have shown that people with AN dem-
onstrate reduced facial expression compared to
controls in response to film clips or pleasant pic-
tures. Watson et al.24 found that women with AN
find female faces less rewarding and avoid looking
at their faces, spending less time looking into the
eye region than controls. The authors of this study
argued that this altered social reward processing in
AN may directly contribute to impaired social func-
tioning in this illness.
In addition to these experimental studies, one
study was identified in the literature which
employed a self-report measure. Davis and Wood-
side reported that individuals with AN demonstrate
significantly higher physical anhedonia scores in
comparison to bulimia nervosa (BN) patients.
Within this study, physical anhedonia was defined
as the degree to which individuals are rewarded by
physical sensations, such as touching, feeling,
movement, and eating. One study which has
explored social anhedonia in people with BN in
comparison to those with AN found that there was
no difference between the illness subtypes.25
2 International Journal of Eating Disorders 00:0 000–000 2012
In summary, limited empirical studies are avail-
able to help us to understand the construct of
social anhedonia in people with AN and BN. This
line of enquiry could be useful, as research in EDs
has highlighted the importance of interpersonal
and emotional processing skills on treatment out-
comes in AN26,27 and the negative impact of sus-
tained social impairment on illness prognosis.28,29
Exploration of the presence of social anhedonia
could help us to understand more about the
nature of the observed interpersonal difficulties in
people EDs.
Whereas social anhedonia refers to the dimin-
ished capacity to experience pleasure from others,
alexithymia refers to an inability to identify and/or
communicate feelings. The relationship between
social anhedonia and alexithymia is stronger than
that of physical anhedonia.30 It is well recognized
that people with EDs demonstrate high levels of
alexithymia.31,32 We were therefore interested to
know if alexithymia relates to social anhedonia in
people with EDs based on the premise that if peo-
ple are unable to recognize and label their inner
emotions, this will pertain to anhedonia in a social
context as well.
This study aimed to explore social anhedonia in
people with EDs generally, and AN in particular,
using a well-established and widely used self-
report instrument specifically designed to measure
this concept. It was predicted that those with a cur-
rent ED (AN, BN), as well as individuals recovered
from AN, would report significantly higher levels of
social anhedonia than HCs. It was also predicted
that alexithymia would be positively related to
social anhedonia, such that higher levels of alexi-
thymia would be associated with higher levels of
social anhedonia.
Method
Participants
This study received approval from the ethical com-
mittee (ref. 08/H0606/58) of the Institute of Psychiatry
and South London and Maudsley (SLaM) NHS Foun-
dation Trust. All participants gave informed consent
prior to their inclusion in the study. Four groups of
participants were recruited; one with a Diagnostic and
Statistical Manual (DSM-IV)33 diagnosis of AN, who
were recruited from inpatient and outpatient ED serv-
ices across the SLaM Trust; a second group with a cur-
rent diagnosis of BN, who were recruited from a spe-
cialist outpatient department within SLaM’s ED serv-
ices; a third group of individuals who had recovered

from AN, recruited from the research volunteer data-
base held within the section of EDs at the Institute of
Psychiatry and a comparative sample of HCs with no
personal or family history of psychiatric illness who
were recruited via advertisements in the local commu-
nity.
Exclusion criteria for all groups were nonfluent English
or a history of head injury. Inclusion age was 18–55, as
the ED department from where recruitment took place
treats people within this age range. Participants were
considered recovered if they reported restored, regular
menstruation for at least the previous year, did not report
clinically significant scores on the Eating Disorders Ex-
amination Questionnaire (EDE-Q)34 and if their body
mass index (BMI) had been 18.5 or above for at least the
previous year. Questions from the Structured Clinical
Interview for DSM-IV disorders (SCID) Extended Module
H35 were used to ascertain a previous episode of AN
based on DSM-IV29 criteria.
Measures and Procedure
Demographic and Clinical Information. Participants
self-reported their age, ethnicity, and years of education.
In addition, duration of illness in the clinical groups was
obtained from their clinical notes. At the beginning of the
assessment, the research version of the SCID35 was
administered by a trained researcher. This highlighted
current and past Axis I psychiatric comorbidity in
patients and was used as a screening tool for HCs. The
following self-report measures were completed by all
participants.
The Revised Social Anhedonia Scale (RSAS). This is a
40-item true/false inventory used to assess social anhe-
donia.36 It has high internal consistency and test–retest
reliability37 and has been widely used21,38 in studies of
individuals with schizophrenia and at-risk populations
with alpha coefficients above .80. Internal consistency for
the current study was .83. Pelizza and Ferrari39 recom-
mend a cut-off of =12 to suggest the presence of signifi-
cant, functionally impaired social anhedonia.
Eating Disorder Examination Questionnaire (EDE-Q). This
36-item self-report questionnaire is a measure of psycho-
pathological and behavioral indicators of disordered eat-
ing.34 It is derived from and scored in the same way as
the eating disorder examination interview schedule
(EDE). The EDE-Q provides a global score and has four
subscales measuring dietary restraint, eating concern,
weight concern, and shape concern. Subscale and global
scores range from 0 to 6, with higher scores representing
greater pathology. In the current study, the overall Cron-
bach alpha coefficient was .93.
Depression, Anxiety, and Stress Scale (DASS). This is a
21-item measure with 7 items in each of the three
subscales.40 The DASS 21 is a short form of the origi-
International Journal of Eating Disorders 00:0 000–000 2012
ANHEDONIA IN EATING DISORDERS
nal 42-item measure and therefore when the final
score for each subscale is calculated, it is multiplied
by 2. Internal consistency for the current study
using Cronbach alpha coefficient was .87 for the total
score.
The Toronto Alexithymia Scale (TAS-20). This is the
most widely used measure of alexithymia.41 It consists of
20 items loading onto three subscales: difficulty identify-
ing feelings and distinguishing them from bodily sensa-
tions, difficulty describing feelings to others, and an
externally oriented style of thinking. A score of \51 indi-
cates nonalexithymia, =61 indicates alexithymia, and 52–
60 shows possible alexithymia. Bagby et al. found the
TAS-20 has good internal consistency for the total score
(a 5 .81) and acceptable internal consistency for the sub-
scale scores.
Statistical Analysis
SPSS version 15 was used to analyze the data. The data
were inspected using histograms and Kolmogorov-Smir-
nov tests to assess assumptions of normal distribution.
The main outcome measure, the social Anhedonia total
score, was normally distributed, and so a one-way
ANOVA was applied to analyze between group differen-
ces. Alpha was set at p \ .05 unless Bonferroni’s correc-
tion for multiple comparisons was applied as indicated
below. Cohen’s d42 (mean1 2 mean2/pooled standard
deviation) was calculated to provide effect sizes for nor-
mally distributed data, with an effect size of 42 Correla-
tions were used to assess relationships between variables.
Partial correlation was used to assess the relationship
between two variables, while controlling for the potential
confounding effect of depression and anxiety, measured
by the DASS.
Results
Clinical and Demographic Data
In total, 148 participants took part in the study;
91 had an ED (AN 5 72 and BN 5 19). There were
14 participants in the recovered AN group and 43
HCs.
Those with AN and BN both reported comor-
bid anxiety problems, assessed using the SCID.
In the AN group, 22.2% (n 5 16) had panic dis-
order, 16.7% (n 5 12) had agoraphobia, 30.6%
(n 5 22) had social phobia, 20.8% (n 5 15) had
obsessive compulsive disorder, and 50% (n 5 36)
had symptoms of generalized anxiety disorder. In
the BN group, 6.3% (n 5 2) had panic disorder,
6.3% (n 5 2) had agoraphobia, 31.3% (n 5 6)
had social phobia, 6.3% (n 5 2) had obsessive
compulsive disorder, and 31.3% (n 5 6) had gen-
3
TCHANTURIA ET AL.

TABLE 1. Clinical and demographic characteristics of the healthy control, eating disorder, and recovered AN groups
HC (N 5 43) AN (N 5 72) BN (N 5 19) Rec AN (N 5 14) Test Statistics

Age 26.5 (8.8) 25.7 (7.5) 31.0 (11.7) 25.2 (8.7) F(3,145) 5 2.06, p 5 .108
BMI 21.6 (1.7) 14.5 (1.8) 21.0 (2.1) 21.1 (1.9) F(3,143) 5 149.67, p 5 .001
Duration of illness N/A 9.6 (7.0) 11.1 (9.4) 3.8 (2.6) F(2,98) 5 4.76, p 5 .012
DASS total 5.8 (4.6) 38.3 (14.9) 36.2 (14.1) 15.2 (10.7) F(3,144) 5 72.45, p 5 .001
DASS depression 1.2 (1.1) 13.9 (5.7) 13.5 (6.6) 4.1 (4.3) F(3,144) 5 72.71, p 5 .001
DASS anxiety 1.3 (1.5) 10.7 (5.9) 9.3 (3.9) 3.5 (3.6) F(3,144) 5 43.94, p 5 .001
EDEQ-global .7 (.7) 4.0 (1.4) 3.8 (1.1) 1.8 (.9) F(3,140) 5 77.51, p 5 .001
TAS total 37.9 (8.2) 60.4 (13.7) 56.8 (13.4) 46.3 (13.1) F(3,127) 5 30.59, p 5 .001
HC 5 healthy control group; AN 5 anorexia nervosa group; BN 5 bulimia nervosa group; Rec AN 5 recovered AN group; test statistics are ANOVAs and
descriptive statistics are means followed by standard deviations in parentheses.N/A 5 not applicable. BMI 5 body mass index (weight/height2). Where let-
ters in superscript differ, group means are significantly different, same letters indicate non-significant differences between the groups.

TABLE 2. Scores for the social anhedonia scale for the healthy control (HC), eating disorder (AN, BN), and recovered
AN (Rec AN) groups
HC (N 5 44) AN (N 5 72) BN (N 5 19) Rec AN (N 5 14)

Social anhedonia scale 5.5 (4.7)a 16.4 (8.6)b*; d 5 1.28 17.2 (8.3)b*; d 5 1.52 9.5 (6.7)a; d 5 .48
HC 5 healthy control group; AN 5 anorexia nervosa group; BN 5 bulimia nervosa group; Rec AN 5 recovered AN group. Analysis is based on a one-
way ANOVA and descriptive statistics are means followed by standard deviations in parentheses. Where letters in superscript differ, group means are signif-
icantly different, same letters indicate nonsignificant differences between the groups. d 5 Cohen’s D effect size for each group compared with HCs, with
an effect size of \.2 defined as small, \.5 defined as medium, and \.8 defined as large (Cohen 1988). * 5 significantly different to healthy controls at p
\ .001.

eralized anxiety disorder symptoms. Of those
currently ill with BN, 43.8% (n 5 8) reported a
past history of AN. There were low rates of drug,
alcohol, and medication abuse in the currently
unwell groups. No BN participants endorsed dif-
ficulties with any of these substances. A small
proportion of the AN group (4.2%, n 5 3)
reported current alcohol abuse and 23.1% (n 5
3) of those in the recovered group reported a
past history of alcohol abuse.
Those in the AN group had an average duration
of illness of 9.69 years (SD 5 7.09) and those with
BN had had the disorder for 11.15 (9.47). The recov-
ered group reported suffering from the illness for a
fewer number of years (mean 5 3.90, SD 5 2.62).
Table 1, below, provides clinical and demo-
graphic information for the four participant groups.
The groups were similar in terms of age. Partici-
pants with AN and BN were significantly more
depressed, anxious, and stressed, with higher levels
of ED symptomatology than HCs and those who
had recovered. Those with AN and BN and individ-
uals recovered from AN had significantly higher
levels of alexithymia than HCs.
Data for the Revised Social Anhedonia Scale
Table 2, below, provides means, standard devia-
tions, and effect sizes for the clinical, recovered,
and HC groups for the RSAS.
Participants with AN and BN both reported sig-
nificantly higher levels of social anhedonia than
HCs, with large effect sizes. There was a small
sized, albeit, nonsignificant difference between
those who had recovered from AN and HCs (t 5
1.518, df 5 55, p 5 .14) and the recovered group
reported significantly less social anhedonia
than those currently ill with AN (t 5 2.801, df 5 84,
p 5 \.006). There was no significant difference in
self-reported social anhedonia between those with
AN and BN (t 5 2.376, df 5 89, p 5 .71). Within the
AN group, 70.83% (n 5 51) scored above the sug-
gested cut off for the RSAS of =12. Of those with
BN, 47.5% (n 5 14) scored above the cut off;
14.29% (n 5 2) of the recovered participants scored
above the cut off, and 11.63% (n 5 5) scored above
the cut off. The Figure 1 illustrates the significantly
higher social anhedonia reported by those cur-
rently unwell with an ED in comparison to HCs
and the intermediate profile of the recovered
group.
Correlations Between Clinical Characteristics
and Social Anhedonia
Table 3 below provides correlation coefficients
between clinical and demographic characteristics
and self-reported social anhedonia for the entire
sample and the AN group.
For the entire sample, there was a significant
negative correlation between social anhedonia and
BMI, such that lower levels of social anhedonia
were related to higher BMI. There was a significant
positive correlation between social anhedonia and
ED symptoms, measured using the EDE-Q, such

4 International Journal of Eating Disorders 00:0 000–000 2012

 ANHEDONIA IN EATING DISORDERS

that higher levels of social anhedonia were related
to higher levels of ED symptoms. There was a sig-
nificant positive correlation between social anhe-
donia and depression, anxiety and stress, measured
using the DASS, such that higher levels of social
anhedonia were related to higher levels of self-
reported depression, anxiety, and stress. There was
a significant positive correlation between social
anhedonia and self-reported alexithymia, meas-
ured using the TAS-20, such that higher levels of
social anhedonia were related to higher levels of
alexithymia. When only the AN group was consid-
ered, the relationships remained the same for social
anhedonia and the DASS, EDEQ and the TAS. The
relationship between BMI and social anhedonia
was no longer significant. There was a significant
positive relationship between social anhedonia and
age, as well as social anhedonia and duration of ill-
ness, such that higher levels of social anhedonia
were related to AN patients being older and having
a longer duration of illness.
As shown in Table 3, a number of partial correla-
tions were carried out, where depression (DASS-
Depression) was controlled for in the analysis. It
FIGURE 1 Total social anhedonia scores for the anorexia
nervosa, bulimia nervosa, recovered and healthy control
groups.
was found that only alexithymia and duration of ill-
ness maintained a significant correlation with the
social anhedonia scale within these partial correla-
tions.
Given the significant correlation between social
anhedonia and depression, measured using the
DASS, those with EDs were split around the ED
mean for depression into two groups: those with an
ED who scored equal to, or above the mean for
depression and those with an ED who scored below
the mean for depression. A t test was subsequently
carried out to compare self-reported social anhedo-
nia in these groups. Those with an ED who scored
above the mean (n 5 51) had significantly higher
social anhedonia scores (mean 5 19.61, SD 5 8.43)
than those with an ED (n 5 39) who scored below
the mean for depression (mean 5 13.03, SD 5
7.01), (t 5 3.943, df 5 88, p 5 .01).
Those in the ED group scoring above the mean
for depression were most likely to have a comorbid
major depressive episode and this group scored
significantly higher for self-reported social anhedo-
nia than Pelizza and Ferrari’s39 sample of 65 adults
with clinical depression (mean 5 13.07, SD 5 5.66),
(t 5 5.251, df 5 51, p 5 .001).
A linear regression was used to explore the signif-
icant predictors of social anhedonia within the ED
group. The overall model was significant (F(5,75) 5
9.013, p 5 .001) and of the predictors entered
using the enter method (BMI, age, years of illness,
depression measured using the DASS and EDE-Q
global score), years of illness (t 5 2.125, B 5 .296,
p 5 .037), and depression measured using the
DASS (t 5 3.737, B 5 .423, p 5 .001) were both
significant predictors of social anhedonia, explain-
ing 32.2 and 58.9% of the variance in social anhe-
donia, respectively.

Discussion
The aim of this study was to explore social anhedo-
nia in people with current EDs, people with a past

TABLE 3. Pearson correlations for the total sample and the AN group only for the social anhedonia scale and
demographic and clinical variables
Age Duration of Illness BMI EDE-Q DASS TAS

Social anhedonia scale total sample n 5 148 .14 N/A N/A .53a .63a .54a
Toronto alexithymia scale total sample n 5 148 2.11 N/A N/A .67a .70a —
Social anhedonia scale AN group only n 5 72 .25a .38a 2.05 .38a .48a .40a
Toronto alexithymia scale AN group only n 5 72 .49 .05 2.001 .42a .37a —
Social anhedonia scale AN group only with depression partialled out .24 .33a .07 .15 N/A .31b
a
Correlation is significant at the .01 level (two-tailed).
b
Correlation significant at .05 level (two-tailed). N/A 5 not applicable; AN 5 anorexia nervosa group; TAS 5 Toronto Alexithymia Scale; EDEQ 5 eating
disorders examination questionnaire; DASS 5 depression anxiety and stress scale, 21 item version. N/A 5 not appropriate.

International Journal of Eating Disorders 00:0 000–000 2012 5

TCHANTURIA ET AL.
history of AN, and a comparison group of HCs. As
expected, people with current AN or BN had higher
self-reported social anhedonia than people without
EDs. The small sample of people recovered from
AN had a profile that fell in between those who
were currently ill and HCs. It is possible, therefore,
that heightened social anhedonia could be present
to a higher degree in people with a history of EDs
and that this factor is exacerbated in the ill state,
due to the effects of starvation as highlighted by
the Minnesota Starvation Studies.18 In relation to
this, social anhedonia has been reported as being a
promising indicator of vulnerability to developing
schizophrenia.21 However, it is also possible that
higher levels of social anhedonia are a scar of the
illness and longitudinal studies would be required
to explore this in more detail.
The significant positive correlation between
social anhedonia and depression was large (both
for the AN only group and for the whole sample),
suggesting that there is significant overlap between
these two constructs and that the same causal fac-
tor may be implicated in both depression and
social anhedonia. Those with EDs who reported the
highest rates of depression had greater social anhe-
donia than those reporting fewer symptoms of
depression, although both those with EDs scoring
above and below the mean for depression scored
above the cut off of 12 suggested for the scale.39 It
is possible that the anhedonic component of
depression is expressed in EDs in a social form,
particularly because of the interpersonal difficulties
experienced by this group.15–17 It may also be that
high levels of social anhedonia may predispose
someone to depression, as they may not get psy-
chological benefit from activities that normally
promote positive mood (e.g., being with others). It
was of note that the regression showed that years
of illness and depression both explained a large
amount of the variance in social anhedonia for
those with EDs and this suggests that the develop-
ment of clinical interventions for social anhedonia
in people with EDs might work best if they target
those with a chronic illness and work with the indi-
vidual to help improve symptoms of depression in
both a general and social context.
When associations between social anhedonia
and clinical and demographic variables were
explored, strong significant correlations were found
between self-reported depression, anxiety, ED
symptoms, BMI, and alexithymia. Therefore, diffi-
culties identifying and expressing feelings are
related to diminished pleasurable experience of
social relationships. Furthermore, higher levels of
6 International Journal of Eating Disorders 00:0 000–000 2012
social anhedonia were related to a longer duration
of illness in those with AN.
The data collected in this study do not support
Davis and Woodside’s findings that individuals with
BN are less socially anhedonic than those with AN.
However, our results should be interpreted with
caution given the small sample size of the BN group.
The data demonstrate that people with a current
ED diagnosis report finding it difficult to experi-
ence pleasure from their interactions with other
people. This is consistent with previous research
suggesting that people with AN, in particular, have
diminished capacity to experience pleasure or
reward from normally pleasurable or rewarding
stimuli. The concept of high levels of social anhe-
donia in people with EDs is relevant to the discus-
sion around recent suggestions that EDs (AN in
particular) may share a number of common fea-
tures with other disorders that are characterized by
social and interpersonal dysfunction, such as autis-
tic spectrum disorders (ASD) and psychosis.43,44
Indeed, a similar number of people in the AN group
(70.83%) scored above the cut off for social anhedo-
nia to those with schizophrenia (65%) and the
number of people with BN scoring above the cut
off (47.5%) was similar to those with depression
(45%).39 It would be interesting to explore in future
studies whether self-reported social anhedonia is
related to objective measures of social cognition
and social reward. For example, there is research to
suggest that people with AN avoid looking at the
eyes and faces of others,24 as do people with ASD45
and psychosis.46 This has important implications
for social interaction, as the eyes are a rich source
of social information. It would be interesting to see
whether social anhedonia mediates the relation-
ship between reduced eye contact and actual level
of social functioning in the future.
Limitations
Only one self-report measure for social anhedo-
nia was used for this study. For future studies, addi-
tional interviews and experimental (performance-
based task) designs might contribute to improved
validity and reliability of findings. It would have
also improved the reliability of the findings to have
had a larger sample of recovered participants with
both AN and BN. Additionally, the sample was self-
selecting which may have biased the data and the
exclusion criteria applied to the HC group may
have resulted in these individuals being less repre-
sentative of a community sample.
It would be important to know if a factor such
as social anxiety contributes to social anhedonia.

It is possible that if you are anxious around people
you may not get much enjoyment from them.
Therefore, including a measure of social anxiety
would be helpful in future studies. Furthermore, it
was beyond the scope of this design to explore
potential causal links between depression, social
anhedonia, and EDs. Causality could be investi-
gated in future studies.
Clinical Implications
The findings reported here support anecdotal
clinical reports of high levels of social anhedonia
in patients with EDs. Indeed, this was the first
study to actively explore self-reported social
anhedonia in an ED population. Given the large
effect sizes in patients groups it might be worth-
while addressing and targeting social anhedonia
in psychological interventions. Furthermore, a
lack of pleasure derived from interacting with
others may contribute to the interpersonal diffi-
culties that are often cited as maintaining factors
for EDs.1,47 Tackling this important potential
maintaining factor in treatment is likely to be a
worthwhile endeavor. This might involve psycho-
education and increasing awareness about social
anhedonia, helping patients to develop strategies
regarding change in this domain, and therapist-
led experiential exercises to model and help rein-
force normal social interaction. All of these may
be beneficial in facilitating the long process of
recovery. The results of this study were in fact
discussed with a group of our service users and
their feedback was that it might be very useful
to think together with clinicians about social sit-
uations, not involving food, which could help
their reintegration back into the community.
Conclusion
Social anhedonia is part of the multiple problems
present in EDs. Specifically, addressing this in treat-
ment interventions could improve functional out-
comes in these disorders.
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