Eating disorders are very interesting disorders to examine and understand, as they are often found in combination with other disorders. In fact, researchers have found strong co-morbidities (two or more disorders) between eating disorders and several other psychological problems, including anxiety, depression, social phobia, panic disorder, mood disorders, obsessive-compulsive disorder, post-traumatic stress disorder, and substance abuse. A 2008 study (by Salbach-Andrea et al.) examined comorbidity of psychiatric diagnoses in adolescent girls with anorexia and found 73.3% of the girls had a comorbid diagnosis, including mood disorders (60.4%), anxiety disorders (including OCD) (25.7%), and substance use disorders (7.9%). Furthermore, another recent study showed that 65% of those with an eating disorder also met criteria for an anxiety disorder (which at the time included OCD under DSM-IV. Amongst these individuals anxiety disorders preceded the development of the eating disorder in 69%.
One comorbid condition known to have a strong association with eating disorders is obsessive-compulsive disorder (OCD). Interestingly, a recent paper published on a longitudinal multigenerational family/twin study found that females with OCD had a 16-fold increased risk of having a comorbid diagnosis of Anorexia Nervosa, and males with OCD had a 37-fold increased risk. However, though several studies have focused on the prevalence between eating disorders and OCD, little is known about the specific relationship that exists between OCD and eating disorders. In this article, we will seek to explore some of the known information regarding eating disorders and OCD. We will review what we know about the comorbid relationship of OCD and eating disorders, as well as treatments that are available to assist people suffering from these conditions.
Over the last couple of years, clinicians and researchers have made some shifts in the way they are conceptualizing OCD. In the Diagnostic and Statistical Manual (a psychiatric manual used to classify disorders), OCD was previously grouped with other anxiety disorders, such as generalized anxiety (e.g., anxiety in many areas of life) and panic disorder (e.g., anxiety with panic attacks). However, with the release of the new edition of the DSM-5, OCD has been moved to its own category of disorders that is characterized by obsessive thoughts and/or compulsive behaviors. This category includes disorders such as obsessive-compulsive disorder (OCD), body dysmorphic disorder (e.g., seeing parts of the body very differently in size/shape than they are in reality), hoarding disorder (e.g., holding onto items without being able to let them go), trichotillomania (e.g., hair-pulling disorder), and excoriation (e.g., skin-picking) disorder.
According to the American Psychiatric Association, OCD is defined as the presence of obsessions, compulsions, or both.
Obsessions are defined as:
- Recurrent and persistent thoughts, urges, or images that are experienced, at some point during the disturbance, as intrusive and not wanted, and cause noticeable anxiety and distress
- The individual attempts to suppress or ignore such thoughts, impulses, or images or to counteract them with another thought or action
Compulsions are defined as:
- Repetitive behaviors or mental acts in response to an obsession or according to rules that must be followed rigidly
- The behaviors or mental acts are directed at preventing or reducing distress or preventing some dreaded incident or situation; however, these actions or mental acts either are not connected in a way that could realistically neutralize or prevent whatever they are intended to address, or they are obviously excessive.
Another diagnosis in the DSM-5 that is often confused with OCD is obsessive-compulsive personality disorder (OCPD), which is a type of personality disorder characterized by perfectionism, an overwhelming desire for order and control, rigid following of rules, codes, or regulations, and unwillingness to yield responsibilities or give responsibilities to others. The name of the two disorders is similar, the OCPD diagnosis differs from OCD in the sense that people with OCD typically have awareness that their thoughts are irrational and unrelated to the issue at hand; whereas those affected by OCPD believe that their way of doing things is the only way of doing things and are typically related to everyday tasks. Now, it is important for people to understand that a personality disorder is NEVER diagnosed under the age of 18. This is because the personalities of children are still developing, which means we have the opportunity to also change ineffective or unhelpful ways of coping in the world!
Which Came First, The Chicken or The Egg?
A fascinating relationship exists between eating disorders and OCD, in that many folks with eating disorders have behaviors and thought patterns that are very rigid and obsessive in nature! This makes sense, as eating disorders are commonly associated with compulsive behaviors such as dietary restriction, over-exercising, bingeing, purging, and obsessive thought patterns related to body and shape. Essentially, we have a “chicken and egg” phenomenon here – meaning that it is always critical to identify whether the rigid patterns were present before the eating disorder began or rather if they are a consequence of the eating disorder. The reason this makes a difference is because it allows us to understand whether the eating disorder is a consequence of the OCD or, in contrast, if the eating disorder was a precursor to the OCD.
Dr. Andy McGarrahan, a clinical psychologist and OCD/eating disorder expert, agrees with this stating, “A patient may begin to use one disorder to cope with the distress created by the other and vice versa. For example, a patient with an eating disorder may perform rituals with food at meals to manage distressing thoughts about weight gain. Likewise, a patient trying to manage the anxiety related to obsessive thoughts or images may cope with this distress by restricting their food.” Either way, we need to treat both issues, but it helps us to determine how to most effectively treat the person.
When the chicken comes first. It is very common for people who never had OCD prior to an eating disorder to develop “ODC-ish” patterns in the process of eating disorder progression. In fact, several studies have assessed the prevalence of obsessive-compulsive disorder among those with an eating disorder, and prevalence rates have been described as high as 40%.
One longitudinal study found anorexia to be seventeen times more likely in individuals with OCD than if left to chance alone. Compulsive behaviors found in eating disorders are often compared to those with OCD due to the obligatory and repetitive nature of the disorder. However, they also differ in one significant detail. In individuals with eating disorders, these obsessive thoughts and compulsive behaviors are primarily focused on weight, shape, size, and achieving the “thin-ideal.” The prevalence of compulsive behaviors may differ across diagnoses and presentations of the eating disorder. For example, among individuals diagnosed with anorexia nervosa (AN), 80% of restricting-type AN report compulsive over-exercising, compared to 43% of binge/purge-type AN.
When the egg comes first. When looking at the onset of OCD and eating disorders, many studies provide evidence for the OCD preceding the eating disorder. In fact, in one such study of over 600 participants with eating disorders, 41% were found to have OCD and 20% were found to have social phobia; the researchers indicated that nearly all of the comorbid OCD and social phobia participants were found to have developed their disorders prior to onset of the eating disorder.
Other studies have shown that obsessive-compulsive symptomatology can serve as a risk-factor for developing anorexia nervosa. Dr. McGarrahan notes that recognizing obsessive thoughts, images and impulses are not necessarily as easy as it may seem, as they are not always observable, as some may be mental rituals like counting, praying, etc. He further notes that even when compulsions are performed outwardly, the patient may attempt to hide them from others due to shame or embarrassment making it hard for parents to know what is going on. Interestingly, Dr. McGarrahan reports, “because OCD takes up time and energy, parents should take note if their child begins to take longer and longer with seemingly routine tasks such as hand-washing, reading a book, or simply leaving a room or the house. In addition, obsessive thoughts tend to disrupt concentration which might result in homework not getting done, distraction during class or lower grades on tests and quizzes. Teachers and parents might mistake this for lack of effort or problems associated with ADHD.”
Due to the complex nature of these disorders, the current consensus is that a multidisciplinary approach is ideal when treating an individual with a comorbid eating disorder and OCD. One study, which focused on development of a cognitive-behavioral approach (CBT) paired with exposure and response prevention (ERP) in a residential treatment setting, found that patients showed significant decreases in severity of OCD, severity of eating disorder, and depression. These studies indicate that a multi-faceted approach that targets OCD tendencies with a focus on eating and body-image concerns can be a highly effective treatment option. Other research has suggested that a multidisciplinary approach including behavioral, neurobiological, and therapeutic methods may be best suited for these types of cases due to the numerous biological, psychological and social factors that impact the development and manifestation of these disorders.
Dr. McGarrahan notes that in his professional opinion he finds CBT and medications paired together to be most effective as he states, “The CBT therapist is working on cognitive restructuring while helping the patient with exposure and response prevention. The therapist wants to provide the patient with “tools” to help manage the anxiety that comes with OCD that he or she can utilize during repeated exposure and response prevention. The medication is another tool in that process.” In addition, Dr. McGarrahan recommends that parents become educated on the nuances of OCD if they think it may be impacting their child. He suggests John March, M.D.’s book “Talking Back to OCD,” as a helpful guide to help parents, as well as gathering information from respected organizations such as the International OCD Foundation and the National Institute of Mental Health.
About The Authors:
Ashlyn A. Parides, BA, is a milieu therapist at the Center for Pediatric Eating Disorders of Children’s Health/Children’s Medical Center Plano. She primarily works with patients in the inpatient and partial hospitalization levels of care and serves on the Alumni Committee for the program. Her research interests include risk factors and prevention of eating disorders, as well as treatment outcomes for patients with a history of bullying or trauma. Ms. Parides is a graduate of Austin College with a degree in Psychology and plans to pursue graduate education in the upcoming year with a focus on eating disorder intervention and clinical outcomes.
Kelsey M. Latimer, PhD, is the lead psychologist in the Center for Pediatric Eating Disorders of Children’s Health/Children’s Medical Center Plano. She works in all levels of care, including inpatient and partial hospitalization and leads the intensive outpatient program. Her research is focused on eating disorder prevention and intervention, and clinical outcomes of eating disorder programs. She is also an Assistant Professor of Psychiatry at the University of Texas Southwestern Medical Center.
Sonia Schwalen, PhD, is a psychologist at the Center for Pediatric Eating Disorders at Children’s Health Plano and is an Assistant Professor in Psychiatry at UTSW. Her primary areas of research include the spectrum of pediatric eating disorders (e.g., anorexia nervosa, bulimia nervosa, binge eating disorder, and obesity), linking systems of care for parents and families, and issues in supervision.
They can be reached through the Center for Pediatric Eating Disorders.
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Written – 2016