OCD & Eating Disorders: Connections, Symptoms, & Treatments

What Is Obsessive Compulsive Disorder (OCD)?

People with OCD struggle with recurrent intrusive thoughts, urges, or mental images (obsessions), as well as compensatory behaviors aimed at decreasing their anxiety (compulsions).¹ These thoughts and behaviors feel out of the person’s control and interfere with life and overall well-being. OCD can manifest in a number of ways for different people, depending on the subject of their obsessions.

Common symptoms of OCD include:

Obsessions: 

• Intrusive thoughts (often about taboo or forbidden subjects involving sex or religion)
• Fear of contamination
• Aggressive thoughts and fear of harming others or self
• Rigidity – symmetry, order, or things feeling “just right”
• Health-related obsessions

Compulsions:

• Excessive cleaning or hand washing
• Checking behaviors
• Counting behaviors
• Ordering/arranging
• Obsessive research regarding diseases

What Are Eating Disorders?

An eating disorder involves a severe disturbance in someone’s eating patterns that may result in extreme physical and mental harm. Symptoms vary between different types of eating disorders, but all are about more than just food. Eating disorders are the second deadliest mental health condition, and are often related to deeper thoughts and emotions rooted in past trauma and low self-esteem. 

Common symptoms found in eating disorders include:

• Preoccupation with body image
• Intense fear of weight gain
• Restricted eating (counting calories and decreased variety of food)
• Preoccupation with food and eating
• Self-esteem defined by perceptions of body and appearance
• Mood fluctuations
• Weight loss/gain
• Other physical symptoms (for example, brittle hair and nails, low blood pressure, gastrointestinal issues, and/or electrolyte imbalance)

How Often Do OCD and Eating Disorders Co-Occur?

People with eating disorders are more likely to experience OCD—between 11-69%—versus those without eating disorders—10-17%.² A 2020 meta-analysis of literature on eating disorders and OCD found that “slightly less than one fifth of ED patients also ha[d] an additional lifetime diagnosis of OCD.”³

Can OCD Cause Eating Disorders?

While comorbidity is high, there is no direct link between eating disorders and OCD, and one does not necessarily cause the other. Some have suggested that EDs should be considered part of the OCD spectrum; or, that EDs and OCD should be listed under a separate spectrum of disorders characterized by obsessions and perfectionism.² Currently, OCD and EDs exist in distinct categories in the DSM-V (obsessive compulsive and related disorders, and feeding and eating disorders).

Shared Traits Between OCD and Eating Disorders

While OCD and eating disorders are separate conditions, they do share some characteristics, including perfectionism, anxiety, and ritualistic behaviors.

Compulsive & Ritualistic Behaviors

People with OCD rely on compulsive actions to reduce anxiety about their intrusive thoughts. People with disordered eating similarly rely on compulsive behaviors to cope with repetitive thoughts and concerns related to diet and body image.

Anxiety

Anxiety is a prevalent feature in both OCD and eating disorders. People with OCD and eating disorders may experience recurrent intrusive thoughts or obsessions that produce intense levels of anxiety. Consequently, they seek ways to alleviate their stress by controlling their circumstances through ritualistic compulsions or other dysfunctional behaviors. This common symptom can be debilitating and hinder quality of life in either disorder.⁴

Perfectionism

Perfectionism is another trait commonly observed in OCD and eating disorders, and a strong contributor possibly sustaining their comorbidity. Two aspects of perfectionism thought to link EDs and OCD are doubts about basic day-to-day matters and an incessant repetition of behaviors. This performance-related strain can ultimately disrupt various aspects of life like academics, work, relationships, health, and so on.⁴

Inflexible Thinking

An inflexible thought pattern is another common thread between eating disorders and OCD. People with this rigid mindset often become fixated on performing ritualistic or repetitive behaviors. In turn they can get stuck with an inability to interrupt their ritualistic actions and may continue before they’re able to switch gears. Unfortunately, cognitive inflexibility can be overpowering and can worsen symptoms, sustaining their duration.⁵

Key Differences Between OCD and Eating Disorders

Differences between OCD and certain types of eating disorders can be particularly difficult to distinguish, since there can be symptom overlap or comorbidity. However, one clear distinction between OCD and eating disorders is that the obsessions and compulsions in OCD are not generally limited to thoughts and actions related to food and/or body weight.^{4, 6}

Moreover, unlike OCD, people with eating disorders view the disorder as part of their identity, so their thought and behavioral patterns are aligned (ego-syntonic), which in turn sustains the condition. However, someone with OCD is often aware that their thoughts and compulsions are problematic and in conflict with or dissonant to their character (ego-dystonic).

What Do Co-Occurring Eating Disorders and OCD Look Like?

Recent research found that OCD most often co-occurs with anorexia nervosa binge-eating purge type.⁷ However, OCD can co-occur with a variety of different eating disorders. Both EDs and OCD come with a variety of cognitive distortions such as “all or nothing thinking” and “catastrophizing,” and are often related to a desire to gain a sense of control.²

Here are examples of how obsessive thoughts and compulsive behaviors manifest in different eating disorders:

OCD and Anorexia Nervosa

People with anorexia often struggle with rumination about weight, body shape, and appearance. Compensatory behaviors can include compulsive weighing, counting calories, and excessive exercise. They can also struggle with food and meal time rituals including eating foods in a certain order, taking excessively small bites, counting bites or chews, and only using preferred plates and utensils. Anorexia nervosa can also include obsessive checking to make sure food was not prepared with additional oils, butter, or salt. Lastly, individuals might check and recheck to make sure they did or didn’t eat something.

OCD and Orthorexia

A person living with orthorexia will struggle with rigidity about only eating “good” foods, and avoiding “bad” foods. This can lead to obsessions about which foods are “healthy” or “clean” enough to consume, resulting in the avoidance of entire food groups. Obsessiveness in orthorexia can also manifest around meal times (only eating at certain times, leaving a certain number of hours between meals, etc.) and compulsively checking ingredients, nutritional facts, or macronutrients.

OCD and Body Dysmorphia

A person with body dysmorphia will suffer from obsessive thoughts and concerns about appearance. This is often obsession with a specific body part and the individual then does compensatory body checking behaviors to relieve anxiety. For instance, someone might look at their nose in the mirror compulsively, or frequently touch their stomach to try to evaluate if they have gained weight.

OCD and Bulimia Nervosa

Bulimia nervosa is also characterized by obsessive preoccupation with body image and weight gain. Binges are followed by obsessive guilt and shame, which is then dealt with by compulsive purging. Specific rituals are often established around purging, such as order of actions, time of day, and location.

OCD and Avoidant Restrictive Feeding Intake Disorder (ARFID)

ARFID is a disturbance in eating that is not related to body or weight gain. Instead, ARFID relates to a disinterest in food, avoidance of food based on sensory preferences (extreme picky eating), and/or fear of choking or vomiting.⁸

People struggling with ARFID often struggle with obsessions about food contamination/spoiling as related to fear of vomiting, and as a result may compulsively check expiration dates and/or throw away foods. This might also lead to repeated hand washing or avoiding preparing food entirely to protect against contamination.

When to Talk to Your Doctor About Symptoms

While we all may experience mild obsessions or difficulty with body image at some points in our lives, if these obsessions become more severe and persistent, it is important to reach out for professional help. This is especially true if compulsive behaviors (around food or other areas) begin getting in the way of your career, family life, or social connections.

How Are Eating Disorders and OCD Diagnosed?

Since OCD and eating disorders can appear similar, overlap, or co-exist, many people are often misdiagnosed. Thus, it’s critical to find a professional with the clinical experience to perform the proper evaluations and determine which specific condition the person has, if there’s comorbidity, and if so, which concern is mainly triggering the other.²

A mental health specialist can establish a formal diagnosis for disordered eating, OCD, or comorbidity by first examining the person’s thought and behavioral patterns along with the underlying motivating factors. Additionally, they may also conduct further medical exams and tests to review the person’s current health or check for other related complications.

How Are Co-Occurring OCD & Eating Disorders Treated?

Before starting treatment, a clinician should do a thorough assessment to determine which symptoms and behaviors are related to the eating disorder, OCD, or both.

Therapy Options

Both EDs and OCD are typically treated with a combination of cognitive behavior therapy (CBT) and exposure and response prevention therapy (ERP).² Research suggests ERP techniques are particularly effective when these disorders co-occur.⁹ Family therapy may also be helpful, based on the specific patient’s support system and/or their age.

When treating co-occurring EDs and OCD, it is important to remember that malnourishment can contribute to obsessive behavior.¹⁰ Thus, people will likely have more success challenging obsessive thoughts and behaviors as they continue to incorporate nutrition. This speaks to the importance of incorporating nutritional counseling and medical care when treating EDs.

Therapy options for co-occurring OCD & eating disorders include:

• Cognitive behavioral therapy (CBT): CBT focuses on helping individuals reframe irrational and unhelpful thought patterns that reinforce obsessions and compulsions. For example, a therapist might help a patient reframe their obsessive thought that they must lose weight in order to make friends by encouraging them to explore other important aspects of their personality.
• Exposure and response prevention (ERP): ERP works to reduce behaviors by exposing individuals to triggering situations and preventing them from engaging in compulsions. For instance, a therapist might accompany their patient while they eat a food they perceive as “bad,” and help them sit with the anxiety instead of engaging in compulsive exercise.
• Family therapy: Most commonly used to treat eating disorders in adolescents, family therapy approaches like the Maudsley method can also be helpful for adults and those struggling with co-morbid OCD. EDs and OCD can be difficult for family members to understand, and family therapy can provide them with important education about how to support their loved one through the recovery process.

Medications

Medications for OCD may also be used in treatment whether on its own or when co-occurring with an eating disorder; SSRIs are commonly used to treat OCD symptoms. SSRIs often require higher daily doses when treating OCD versus depression.¹¹ Antidepressants, antipsychotics, and mood stabilizers may be used to treat eating disorders or other comorbid but associated conditions.

Getting Help 

Both eating disorders and OCD require specialized training to treat properly, so anyone struggling should seek out mental health professionals who have expertise in these areas. Without a comprehensive treatment plan that addresses both the ED and OCD, it will be difficult to see progress on either front, as these conditions often reinforce each other. You can start by asking your primary care provider for a referral, contacting your insurance company for a list of in-network providers, or using an online therapist directory, where you can sort by specialty and location.

How to Cope with Comorbid OCD & Eating Disorders

If you are struggling with an eating disorder and/or OCD, there are a number of ways to manage symptoms and practice self-care. There are several coping skills that can be helpful in moving towards recovery.

Here are some ways to cope with an ED or OCD:

• Practice meditation: Meditation can be helpful in quieting obsessive thoughts and managing stress.
• Practice mindfulness: Mindfulness can help you ground yourself in the present moment, and relieve symptoms of anxiety that stem from obsessions or food related thoughts.
• Journaling: Sometimes, writing down your feelings can be helpful so as to feel less overwhelmed by the obsessive thoughts in your head. Journaling allows you to do this in a productive and often cathartic way.
• Join a support group: Joining a support group or seeking group therapy can put you in touch with people who are dealing with similar difficulties, so you don’t feel alone in your journey.

Final Thoughts

Living with comorbid OCD and EDs can be challenging, but recovery is possible. If you or someone you know are experiencing an eating disorder and/or OCD, don’t be afraid to ask for help.