OCD & Eating Disorders: Connections, Symptoms, & Treatments

What Is Obsessive Compulsive Disorder (OCD)?

OCD involves recurrent intrusive thoughts, urges, or mental images (obsessions), as well as compensatory behaviors aimed at decreasing 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 OCD obsessions can include: 

• 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

OCD compulsions can involve:

• 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 or gain
• Other physical symptoms, like brittle hair and nails, low blood pressure, gastrointestinal issues, 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 15-18% of subjects studied with an eating disorder also had a lifelong and current diagnosis of OCD.³

Can OCD Cause Eating Disorders?

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

Can Someone Have Food-Related OCD?

Someone can experience food-related obsessions or compulsions in OCD without the centering on weight loss or gain seen in most eating disorders. Food-related obsessions generally fit underneath other subtypes of OCD like harm or contamination. These obsessions generally cause a person to use compulsions like avoiding eating certain foods, hoarding foods, or being the only person to prepare their food.

Common food-related OCD obsessions include:

• Avoiding eating meat for fear it is undercooked
• Avoiding eating certain foods that may carry diseases
• Worries about food being expired or contaminated
• Fears of choking or throwing up related to certain foods
• Worries about preparing foods incorrectly for loved ones
• Obsessing about how foods will be digested or if they will make you feel sick
• Not letting anyone else prepare foods for you
• Monitoring others when they are preparing foods
• Intrusive thoughts of having an allergic reaction to certain foods

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 perfectionistic thoughts linked to OCD and eating disorders involve 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

OCD Vs. Eating disorders: Ego-Syntonic Vs. Ego-Dystonic Conditions

Unlike OCD, people with eating disorders view the disorder as part of their identity, so their thought processes, beliefs about themself, 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).

Signs of OCD

Sometimes OCD compulsions can look very similar to eating disordered behaviors. The key is that someone with OCD engages in compulsions to neutralize their feared obsessions. An example is the compulsion of cutting food into tiny pieces. Someone with OCD might do this to neutralize fears of choking, whereas someone with an eating disorder may do this to hide how much they are eating.

Common signs of OCD related to food are obsessions around contamination, allergic reactions, colors, or textures of food. Also common are the compulsions to monitor others while they prepare food, or to not let anyone else prepare your food.

Here are some outward signs of OCD vs an eating disorder:

• Fears of contaminated, spoiled, or expired foods
• Fears of food being poisoned
• Cutting food into tiny pieces because of fears of choking
• Not eating food prepared by others
• Monitoring others when they prepare food in the kitchen
• Excessively cleaning the kitchen after food preparation to avoid foodborne illness
• Excessive worries about undercooking or incorrectly preparing foods
• Obsessing about unfounded allergic reactions to foods

Signs of an Eating Disorder

Most eating disorders, like anorexia nervosa, binge eating disorder, and bulimia nervosa, present with a preoccupation with weight and shape. Compulsive behaviors are related to the avoidance of gaining weight. There are other eating disorders which cause avoidance of certain food groups for other reasons, like ARFID, which is characterized by avoidance of foods that have unfavorable tastes or textures. All eating disorders involve the intentional controlling of food intake.

Here are some outward signs of an eating disorder:

• Refusing to eat whole food groups, like carbs, because of the belief they cause weight gain
• Calorie counting
• Repetitive weighing
• Restricting food intake
• Excessively exercising prior to or after meals
• Consuming large amounts of water
• Abuse of laxatives or diuretics
• Disappearing after meals, to purge or exercise
• Avoiding eating certain foods because of the texture
• Believing certain foods are “good” and others are “bad”

When to Talk to Your Doctor About Eating Disorder & OCD 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.

What Do Co-Occurring Eating Disorders & 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 eating disorders 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 & Anorexia

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, someone might check and recheck to make sure they did or didn’t eat something.

OCD & 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 & 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 & Bulimia

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 & Binge Eating

People with binge eating disorder struggle with a cycle of consuming large amounts of food in short amounts of time, and experiencing shame following their binging episodes. Both people with food-related OCD and people with binge eating disorder may struggle with feeling in control around food. They may also struggle with impulsive behaviors around food. They may also overeat certain types of foods that have become part of their ritualized behaviors.

ARFID & OCD

ARFID is an eating disorder characterized by food avoidance due to disgust or fear of unappealing foods or textures. Someone with OCD can also experience food aversion related to their obsessions. Research on people who have comorbid ARFID and OCD shows they may avoid foods due to a history of choking or vomiting from eating certain foods, experiencing an upset stomach from food, past food allergy experiences, or bad sensory experiences with food.⁹

How Are Eating Disorders & 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 OCD, an eating disorder, 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 eating disorders 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.¹⁰ Family therapy may also be helpful, based on the specific patient’s support system and/or their age.

When treating co-occurring eating disorders and OCD, it is important to remember that malnourishment can contribute to obsessive behavior.¹¹ 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 eating disorders.

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

• 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.
• 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.
• 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.
• Dialectical behavior therapy: Dialectical behavioral therapy focuses on increasing core life skills of mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance. Through DBT, people with eating disorders and OCD can learn to better regulate emotions, stabilize food-related thoughts, and maintain social relationships without letting food intake and obsessions control these life areas.
• Group therapy: Group therapy offers someone with an eating disorder and OCD the opportunity to feel validated by others going through similar life experiences. Group therapy also provides the space to learn about eating disorders and OCD from a professional, while also practicing new skills with the support of a safe space.

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.¹² Antidepressants, antipsychotics, and mood stabilizers may be used to treat eating disorders or other comorbid but associated conditions.

Getting Help for OCD & Eating Disorders

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 eating disorder and the 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. There are also many online OCD resources for people looking to get support from home, like NOCD, and online help for eating disorders, like Equip Health and Within Health.

How to Cope With Comorbid OCD and 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, such as practicing mindfulness (especially when it comes to mindful eating), journaling, and finding a support group.

Here are some ways to cope with an eating disorder and 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.