Eating disorders are sometimes characterized by obsessive, repetitive thoughts and compulsive, ritualistic behaviors. Statistics show that people with eating disorders are more vulnerable to co-morbid diagnoses such as anxiety disorders and obsessive-compulsive disorder (OCD). Given some of the overlapping traits and features of eating disorders and OCD, treatment providers may struggle to differentiate the disorders. Similarly, clients may present with both disorders, distinct from one another. Understanding the similarities and differences between eating disorders and OCD can help providers develop a more comprehensive understanding of a client’s presentation and can also inform treatment interventions.
What is OCD and How Does It Compare to Eating Disorders?
According to the DSM-5, obsessive-compulsive disorder is characterized by intrusive, repetitive thoughts that lead to compulsive behaviors. The compulsive behaviors are usually intended to alleviate the anxiety associated with the obsessions. The content of an individual’s obsessions and the specific compulsions they engage in can vary across presentations, and many cases of OCD look different from person to person.
As mentioned previously, eating disorders can consist of symptoms that characteristically are similar to the symptoms of OCD. Specifically, people with eating disorders can experience repetitive thoughts about food and body image and engage in ritualistic behaviors. Examples of common ritualistic behaviors in eating disorders include: body checking for any changes in shape and size, weighing self frequently to check for body changes, avoiding foods associated with fear of weight gain, and engaging in rituals around food intake, such as cutting food into tiny pieces or eating foods in a certain order.
An important distinction between OCD and eating disorders lies in the relationship that the individual has with their thoughts and actions. A person with OCD is typically in an ego-dystonic relationship with their thoughts and actions, meaning that they find the obsessions and compulsions in conflict with or aversive to their identity. In eating disorders, the relationship between the individual and their thoughts and actions typically is ego-syntonic, meaning that the person feels aligned with these thoughts and behaviors. This distinction can make a big difference in treatment. People with OCD are typically highly interested in ridding themselves of their thoughts and feelings whereas people with eating disorder may feel more tied to these components of their disorder since it feels like a part of their identity.
Co-Morbidity and Overlap
Treatment providers may see a variety of presentations with OCD when it co-occurs with an eating disorder. A typical presentation is one where an individual has both disorders, and the disorders are unrelated and mutually exclusive from one another. An example of this presentation would be a client with anorexia nervosa who also engages in ritualistic cleaning behaviors. In this example, the cleaning behaviors are completely unrelated to thoughts and feelings associated with the fear of weight gain and restricted food intake experienced in individuals with anorexia nervosa.
Another common presentation would be that the two disorders overlap. Specifically, the obsessions and compulsions observed in OCD are related to the symptoms of the eating disorder. An example of this presentation would be a client with anorexia who engages in ritualistic exercise. This individual may have difficulty interrupting the ritualistic exercise and may have to engage in certain repetitions before they can stop due to the compulsive nature of this behavior. In this example, the exercise rituals are closely related to the thoughts and feelings associated with the fear of weight gain observed in anorexia nervosa. This presentation can make it more difficult to differentiate between the disorders given the overlapping characteristics. Eating disorder practitioners who may struggle to see this distinction should consult with an OCD specialist when possible to establish proper diagnoses.
Because both eating disorders and OCD share overlapping diagnostic characteristics, treatment for both disorders will look similar. One intervention that exists across disorders is exposure therapy. Exposure therapy involves exposing the client to the feared stimulus in order to help them gradually build a tolerance to their fear and develop a new association to that stimulus. In eating disorder treatment, the clients are exposed to food. In OCD treatment, the clients are exposed to whatever fear their obsession takes with an emphasis on clients refraining from their compulsive behaviors. Treatment for a client with both an eating disorder and OCD would share the same emphasis on preventing the compulsive response. For instance, the client would not only be exposed to food but would be coached through refraining from any rituals around food in which they may compulsively engage.
One helpful intervention to use when doing exposure work is an exposure hierarchy. This intervention is designed to help the client and the practitioner identify the feared stimuli that the client will approach in treatment. An exposure hierarchy should build from the least triggering stimulus at the bottom to the most triggering stimulus at the top. Traditionally, exposure therapy involves working from the bottom of the hierarchy and building to the top as the client gradually habituates to the feared stimuli. This intervention is helpful for clients with eating disorders, clients with OCD, and clients with both disorders.
Cognitive treatment may vary across disorders. Most people with OCD realize that their obsessions are irrational but have difficulty coping with these thoughts. People with eating disorders tend to struggle more to see the distortions in their thinking. Therefore, cognitive behavior therapy (CBT) – which includes identifying and challenging these cognitive distortions, may be more effective for people with eating disorders. Contrastingly, acceptance and commitment therapy (ACT), which focuses more on changing a person’s relationship to their thoughts and feelings, would be more appropriate for a person with OCD who already can identify the distortions in their thoughts.
Both eating disorder specialists and OCD specialists likely will see the overlap of these disorders in their work. Identifying the similarities, differences and interventions is an important aspect of treatment for either—or both—disorders.
Bethany Kregiel is a clinician in the adult residential program at Walden Behavioral Care, providing individual and group counseling to people with eating disorders. She received her Bachelor’s degree in Psychology from John Carroll University and her Master’s degree in Mental Health Counseling from Boston College. Bethany is particularly interested in working with individuals with eating disorders and obsessive-compulsive disorder, and she incorporates aspects of acceptance and commitment therapy (ACT), cognitive behavioral therapy (CBT), and exposure therapy into her work with her clients.