Eating Disorders (EDs) and Obsessive Compulsive Disorder (OCD) are psychiatric conditions that often co-occur. Due to the similar nature of ED and OCD behaviors, it can be challenging to decipher if an individual is struggling with an ED, OCD, or both. Obsessive thoughts and compensatory behaviors are central to both conditions. Understanding similarities, differences, and overlap between EDs and OCD can be helpful for seeking help and receiving the most effective treatment.
What Is Obsessive Compulsive Disorder (OCD)?
Individuals with OCD struggle with recurrent thoughts (rumination), urges, or mental images (obsessions), as well as compensatory behaviors aimed at decreasing anxiety(compulsions).6These thoughts and behaviors feel out of the individuals’ 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 the obsessions (also known as the themes).
Common symptoms of OCD 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 (Symmetry OCD), order, or things feeling “just right”
- Healthy-related obsessions
- Excessive cleaning/hand washing
- Checking behaviors
- Counting behaviors
- Obsessive research regarding diseases
What Are Eating Disorders?
Symptoms vary between different types of eating disorders, but all are about more than just food. On the surface, eating disorders are severe disturbances in individuals’ eating patterns that may result in extreme physical and mental harm. 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 Are OCD & Eating Disorders Related?
Many conditions commonly co-occur with eating disorders including anxiety, depression, and post traumatic stress disorders. Comorbidity with obsessive compulsive disorder and eating disorders can be particularly difficult to distinguish, due to symptom overlap. In fact, those with eating disorders are more likely to experience OCD–between 11-69%–versus those without eating disorders–10-17%.1 A 2020 meta-analysis of literature on EDs and OCD found that “slightly less than one fifth of ED patients also ha[d] an additional lifetime diagnosis of OCD.”2
Symptoms of OCD are often present in eating disorders in the form of obsessive dieting, compulsive rituals around eating, and rumination about body image. Individuals with OCD rely on compulsive actions to reduce anxiety about intrusive thoughts. People with EDs similarly rely on compulsive behaviors to cope with repetitive thoughts and concerns related to diet and body image. Additionally, Individuals with EDs and OCD also often share “temperament traits” including perfectionism, impulsivity, and rigidity.2
Can One Cause the Other?
The relationship between EDs and OCD can be complicated, and every individual has a unique experience with these diagnoses. Similarities between EDs and OCD have long been a topic of conversation, and 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.1 Currently, OCD and EDs exist in distinct categories in the DSM-V (obsessive compulsive and related disorders, and feeding and eating disorders) . Nevertheless, while comorbidity is high, there is no direct link between EDs and OCD, and one does not necessarily proceed the other.
Can OCD & Eating Disorders Be Co-Occurring?
A 2021 research article found that OCD most often co-occurs with anorexia nervosa binge-eating purge type.3 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.1
Difficulty controlling thoughts, intrusive thoughts, and perfectionism often perpetuate co-occurring ED and OCD symptoms. Perfectionism is a pattern of negative thoughts about high self standards that are often disconnected from reality, and can contribute to low self-esteem.
Two aspects of perfectionism that bridge EDs and OCD are “doubts about everyday things” and “repeating things over and over.”4 Individuals who struggle with co-occurring EDs and OCD often experience unhelpful rumination about food and body, and as well as obsessions that go beyond these specific topics. For instance, an individual might avoid grocery shopping, due to anxiety about having food in the house (leading to eating more and gaining weight) and fear of contamination related to being in a public place. The individual might repeatedly check their shopping list to reassure themselves that they can move through the store quickly and without picking up unwanted “bad” foods. In this scenario, both conditions create a state of overwhelming anxiety for the individual, as they feel they cannot trust themselves with commonplace activities. In this case, the individual is struggling with obsessive themes about both diet and safety, and the ED and OCD are both co-occurring and interacting.
These thoughts and behaviors are often present in EDs, even if an individual doesn’t have OCD. They may also be exacerbated by the presence of OCD, or even manifestations of particular OCD themes.
Here are examples of how obsessive thoughts and compulsive behaviors manifest in different EDs:
Individuals with anorexia often struggle with rumination about weight (the number on the scale), body shape, and/or 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.
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, macronutrients, etc.
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, an individual might look at their nose in the mirror compulsively, or frequently touch their stomach to try to evaluate if they have gained weight.
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.
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.5
Individuals struggling with ARFID often struggle with obsessions about food contamination/spoiling as related to fear of vomiting, and as a result 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 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 ED, OCD, or both. Both EDs and OCD require specialized training to treat properly, and individuals 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.
Both EDs and OCD are typically treated with a combination of Cognitive Behavior Therapy (CBT) and Exposure Response Prevention Therapy (ERP).1 Research suggests ERP techniques are particularly effective when these disorders co-occur.7 Family therapy may also be indicated, 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.4
Thus, individuals 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:
- 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.
- ERP: This therapy technique 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 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 for OCD may also be used in treatment, when co-occurring with an ED; SSRIs are commonly used to treat OCD symptoms. SSRIs often require higher daily doses when treating OCD versus depression.8 Antidepressants, antipsychotics, and mood stabilizers may be used to treat eating disorders or other comorbid but associated conditions.
How to Cope with Comorbid OCD & Eating Disorders
If you are struggling with an ED 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.
Living with comorbid OCD and EDs can be challenging. If you or someone you know are experiencing an ED and OCD, you can find help! Finding the right therapist from an online directory is a good first step towards healing.
For Further Reading
- Mental Health America
- National Alliance on Mental Health
- OCD foundation
- National Eating Disorders Association
- CBT School – helpful online courses to address anxiety and OCD