Cognitive and Affective Empathy in Eating Disorders: A Systematic Review and Meta-analysis

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Background: Recent models of eating disorders (EDs) have proposed social and emotional difficulties as key factors in the
development and maintenance of the illness. While a number of studies have demonstrated difficulties in theory of mind and
emotion recognition, little is known about empathic abilities in those with EDs. Further, few studies have examined the cognitiveaffective empathy profile in EDs. The aim of this systematic review and meta-analysis was to provide a synthesis of empathy
studies in EDs, and examine whether those with EDs differ from healthy controls (HC) on self-reported total, cognitive, and
affective empathy. Methods: Electronic databases were systematically searched for studies using self-report measures of empathy
in ED populations. In total, 17 studies were identified, 14 of which could be included in the total empathy meta-analysis. Eight of
the 14 studies were included in the cognitive and affective empathy meta-analyses. Results: Meta-analyses showed that while total
empathy and affective empathy scores did not differ between those with anorexia nervosa (AN) and HC, those with AN had
significantly lower cognitive empathy scores compared to HCs (small effect size). Meta-analyses of Interpersonal Reactivity Index sub-scores revealed that AN had significantly lower Fantasy scores than HC (small effect size), indicating that those with AN have more difficulty in identifying themselves with fictional characters. Only 3 studies examined empathy in those with bulimia nervosa (BN) or binge eating disorder (BED). Conclusions: The lowered cognitive empathy and intact affective empathy profile found in AN is similar to that found in other psychiatric and neurodevelopmental conditions, such as autism spectrum disorder (ASD). These findings add to the literature characterising the socio-emotional phenotype in EDs. Future research should examine the influence of comorbid psychopathology on empathy in EDs.
Original languageEnglish
Article number102
JournalFrontiers in Psychiatry
Publication statusPublished - 4 Mar 2019


  • Anorexia nervosa
  • Autism
  • Eating disorders
  • Empathy
  • Insight
  • Self-report


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