Untangling Eating Disorders and OCD

The 10th Annual Veritas Collaborative Symposium on Eating Disorders, co-hosted by The Emily Program, will unite healthcare professionals and eating disorders experts around this year’s theme, “Engaging Science, Unifying Voices, and Transforming Access.” In this article, Ben Eckstein, a speaker at this year’s Symposium, explores the connection between OCD and eating disorders.

Rigid routines. Experiential avoidance. Feeling out of control. Ruminative thoughts. Are we talking about OCD or eating disorders? Maybe both. Are we talking about OCD or eating disorders? Maybe both. If you’ve spent any time treating eating disorders, chances are good that you’ve come across an individual with comorbid Obsessive-Compulsive Disorder (OCD). While rates vary across different types of eating disorders, studies generally show comorbidity rates ranging from 10–44%. This frequent overlap can create diagnostic confusion even for seasoned clinicians. It’s easy to see why: though there are some clear distinctions, the phenomenological similarities can muddy the water and complicate diagnosis and treatment planning.

What Are the Similarities Between Eating Disorders and OCD?

As the name suggests, OCD involves both obsessions and compulsions. Obsessions are repetitive, unwanted thoughts that are experienced as distressing by the individual, while compulsions are behaviors intended to prevent or reduce that distress. These diagnostic criteria are fundamental to OCD; however, the concepts are not necessarily unique. Obsessions may be a hallmark of OCD, but distressing, repetitive thoughts can be found in many mental health diagnoses (GAD, PTSD, etc.). Similarly, in some eating disorders, a preoccupation with food or body shape might be experienced as repetitive or distressing. Compensatory behaviors such as restriction or over-exercise might serve to prevent or reduce distress, much like a compulsion. When viewed strictly through this functional lens, there can be quite a bit of overlap between these disorders. 

What Are the Differences Between Eating Disorders and OCD?

These disorders share many features, but there are differences – some clear and some a bit less clear. Let’s look at this from a couple of angles: when OCD looks like an ED (food-related OCD) and when an ED looks like OCD (ARFID). And of course, just for good measure, let’s also look at the places where they co-occur; it is here where things get a little murky.

Food-Related OCD

Many people are familiar with obsessions related to contamination (dirt, germs, etc.) or harm (leaving the stove on, house unlocked, etc.), but the content of obsessions can actually be incredibly wide-ranging. There are many obsessions related to food, with compulsions that involve limiting or restricting food intake. Here are a few common examples:

• Fear of choking or vomiting
• Fear of ingesting contaminants through food or drinks
• Fear of allergic reactions to food
• Excessive concern about digestion or defecation
• Religious or moral concerns about food
• “Just right” or magical thinking regarding food intake or exercise

As you’ll notice above, food-related obsessions do not involve fears of gaining weight or of changes in body shape. While over-control and food avoidance may be shared behaviors, the feared outcome driving these behaviors is different. It is also worth noting that obsessions in OCD are typically experienced as ego-dystonic; that is, they are foreign, unwanted, and dissonant from the beliefs of the individual. With eating disorders, cognitions are typically more ego-syntonic; the individual identifies with the thoughts and feels that they are consistent with their beliefs and goals. With food-related OCD, medical complications are possible but atypical; with eating disorders, medical concerns are more commonplace.

ARFID

Avoidant Restrictive Food Intake Disorder (ARFID) throws a wrench in our differential diagnosis toolbox. Unlike classical eating disorders, ARFID does not involve a fear of gaining weight or preoccupation with body shape. In fact, many individuals with ARFID can prefer calorie-dense foods which are typically avoided in other eating disorders, while eschewing what are often considered ”safe” foods, such as fruits or vegetables. There can be fears that mirror food-related OCD (choking, vomiting), though ARFID involves a wider array of experiences driving food avoidance, including fear of trying new foods, sensory sensitivity, disgust, and decreased pleasure and interest in food. These concerns result in avoidance and restriction, though the goal is not to control weight, but to avoid an unwanted experience. 

What About When OCD & Eating Disorders Co-Occur?

We can sometimes gain diagnostic clarity by delving into the fears driving behavior, but we may also find that our examination yields two co-occurring diagnoses. Some examples include:

• A client exercises excessively in an attempt to prevent weight gain. They may simultaneously feel that they need to complete these exercises in a particular way in order to prevent something bad from happening or because a particular order “feels right.”
• A client avoids food with the potential for pesticide use due to a fear of contamination initially, then subsequently determines that they are pleased with their weight loss and continue to widen food restriction.
• A client counts calories throughout their day in order to prevent weight gain; they need their caloric intake at each meal to add up to a “good” number in order to prevent harm to their loved ones.

What Does This Mean for Treatment?

OCD and eating disorders are both fairly specialized fields. Therapists often possess expertise in their client population and treatment modality but can sometimes get stuck when an individual’s presentation deviates from that norm or introduces a complicating comorbidity. Luckily, these disorders share enough in common that there are some strategies to help bridge the gap.

Exposure and Response Prevention (ERP) is a validated treatment for OCD. It involves systematically approaching feared stimuli while removing safety behaviors (compulsions) in order to facilitate new learning (that the feared outcome didn’t happen, the anxiety was tolerable, etc.). Eating disorders provide many opportunities for clients to engage in exposure-based treatment. By approaching meals while removing safety behaviors (restriction, over-control, over-exercise), we can facilitate new learning (distress/fullness are tolerable). Examples might include:

• Constructing meal plans with increasingly challenging foods
• Exposure to avoided situations due to body image concerns
• Eliminating rituals/avoidance related to clothing
• Looking at fashion magazines
• Taking/posting unfiltered pictures
• Eating in front of friends

Sometimes OCD can look like an eating disorder, sometimes eating disorders can look like OCD, and sometimes we encounter both together. Teasing apart these overlapping symptoms can help us to achieve diagnostic clarity and will direct us toward a more effective treatment strategy.

To learn more on how eating disorders and OCD are intertwined, please register for Ben Eckstein and Dr. Steven Tsao’s presentation at this year’s Symposium, “Untangling OCD and Eating Disorders.” See the full agenda here.

About the Author

Ben Eckstein, LCSW, is the founder of Bull City Anxiety in Durham, North Carolina.  He has specialized in the treatment of OCD and anxiety disorders for over a decade, training at the OCD Institute at McLean Hospital prior to opening his practice.  Ben is a board member at OCD North Carolina, serving as secretary and walk committee chair.  In addition to his clinical work, Ben provides training and workshops, dedicated to the dissemination of evidence-based treatment.