If You Have An Eating Disorder, Beware of OCD!
Updated: Oct 24
Jonathan Hoffman, PhD, ABPP
If you or someone you love is diagnosed with an Eating Disorder (ED), it is important to be obsessive-compulsive disorder (OCD) savvy. In DSM-5 TR, ED and OCD are categorized as separate diagnosis that can co-occur. However, obsessive-compulsive (oc) symptomatology is so prevalent in ED (and vice versa, in that many people diagnosed with OCD have eating-related symptoms) that some clinicians, like yours truly, wonder if ED is fundamentally OCD, or perhaps an OCD spectrum condition that is specifically focused on feeding, weight, shape, size or fatness.
Not only do ED and OCD share many symptoms, like obsessiveness, rituals (compulsions) such as repetitively adding up calories or eating according to strict rules, need for control, perfectionism, difficulty dealing with uncertainty, and more, but they also appear to have a similar underlying process - in terms of performing rituals (compulsions) or engaging in avoidance responses to fear (or disgust) triggers that temporarily alleviates feelings of distress but in the long run results in worsening symptoms. Moreover, to this clinician, the way many people with ED describe the inner experience of their symptoms parallels the way those with OCD, or OCD related conditions such as body dysmorphic disorder (BDD), describe theirs. In fairness, many clinicians would not agree with equating ED diagnoses across the board with OCD to the extent that this clinician does, as an article he co-authored and is linked to below takes care to discuss.
Be that as it may, obsessive-compulsive symptoms can be highly connected to ED, like having to chew a certain number of times or get a “just right” feeling before swallowing a feared food. Obsessive-compulsive symptoms also might link to ED via magical thinking, a common feature of OCD - for instance, having horrific thoughts/images of cutting a loved one with a knife that prevents them from eating any foods that have become associated with this fear. However, in those diagnosed with ED oc symptoms could also occur in a way that has no discernible connection to ED, for example, having to place shoes in a certain spot to ward off a fear such as failing a test or impulsively doing something immoral.
One obstacle to identifying oc symptoms in people diagnosed with ED is that they may be overshadowed, understandably, by the priority of medical issues such as malnutrition; or be very subtle and challenging to parse out from the overall clinical picture. Another obstacle is that some people diagnosed with ED may experience oc symptoms in a way that is more self-congruent than is typical for those with OCD in general, and for that reason misperceive the important role these symptoms play in their ED-related issues. On the other hand, however, some people with ED hide their oc symptoms out of embarrassment or shame just like those with OCD alone often do. In people diagnosed with ED, obsessive-compulsiveness as a personality trait must also be differentiated from true OCD-related symptoms. As you can see, oc symptoms occurring in those with ED have a lot of nuances!
The great news is that oc symptoms in people diagnosed with ED may respond well to the same evidence-supported, cognitive-behavioral therapy (CBT) methodology that OCD does, most notably, exposure and response prevention, or ERP. ERP is the most highly research-supported OCD treatment. Basically, ERP helps people develop skills in overcoming fears that are illogical, or magnified out of proportion by actually facing such fears head-on. A typical ERP exercise for someone with an ED might be eating a food they presently would be unable to eat while simultaneously not avoiding feared thoughts about that food that pop up in their minds. Every step of the way, ERP must always be implemented at the patient's pace and never without their consent. It may help to know that many people who at first are afraid to try ERP find that it is actually not as bad as they expected and quite effective! What about medication? The first-line medication approach for OCD is high-dose selective serotonin reuptake inhibitors (SSRIs). Presently, however, the jury still seems to be out regarding their effectiveness in treating oc symptoms in those diagnosed with ED.
It is heartening that in many ED treatment centers obsessive-compulsive symptoms seem to lately be receiving more attention and evidence-supported treatment, but there is a long way to go. In the opinion of this clinician, being as OCD-educated as possible is highly recommended for anyone affected by an ED diagnosis.
An article that discuss ED and OCD in greater depth by Dr. Hoffman and Drs. Dee Franklin, Ciana Mickolus, and Myriam Padron is available at: https://iocdf.org/expert-opinions/are-eating-disorders-ocd/
Lastly, you may want to listen in at https://theocdstories.com/episode/nbi-2/ as Dr. Hoffman and Dr. Dee Franklin are interviewed about ED and OCD by Stuart Ralph on "the OCD Stories" podcast.