It’s no secret that mental health disorders tend to come in groups. These are known as co-occurring disorders. The most common disorders that happen at the same time as eating disorders are depression, anxiety, and PTSD. However, less-common maladies are known to co-occur with eating disorders, and some evidence suggests they may be related. Chief among these is Obsessive-Compulsive Disorder, or OCD.
One of the main misconceptions about eating disorders such as anorexia nervosa, binge eating disorder, bulimia nervosa, and others is that these disorders center on food – how much they eat when they eat, what they eat, and whether the food will cause weight gain. These are certainly part of eating disorders, but there is much more to them. Concerns about body image, a sense of perfectionism, and attempts to establish control over some aspect of what seems like a chaotic life are all important factors as well. Unfortunately, these tendencies lead some people to think eating disorders are a product of vanity or self-obsession. This assumption is misleading and completely false.
Eating Disorders Aren’t Really About Losing Weight
In fact, eating disorders are not really about food or losing weight. They are psychiatric conditions that prompt disordered thoughts and actions that physically affect a person’s health and behaviors. This is similar to OCD in that the condition causes behaviors that are not controllable by the person suffering from it. In either case, the behaviors are what defines the disorder (for example, counting light switch for a person with OCD, or putting a strict calorie limit on oneself with anorexia nervosa); however, in both cases, the behaviors are merely symptoms of the underlying disorder.
Although some eating disorders are not influenced by body image (such as pica, most are. In major eating disorders such as bulimia nervosa or binge eating disorder, body dysmorphia causes a person to think they are overweight, whether or not medical professionals would think this is true. The DSM-5 lists body image difficulties as an underlying factor in each of eh three most common forms of eating disorders, listed below:
- Restriction of energy intake relative to requirements, leading to significantly low body weight in the context of the age, sex, developmental trajectory, and physical health (less than minimally normal/expected).
- Intense fear of gaining weight or becoming fat or persistent behavior that interferes with weight gain
- Disturbed by one’s body weight or shape, self-worth influenced by body weight or shape, or persistent lack of recognition of the seriousness of low body weight.
- Recurrent episodes of binge eating, as characterized by both:
- Eating, within any 2-hour period, an amount of food that is definitively larger than what most individuals would eat in a similar period of time under similar circumstances.
- A feeling that one cannot stop eating or control what or how much one is eating.
- Recurrent inappropriate compensatory behaviors to prevent weight gain such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting or excessive exercise.
- The binge eating and inappropriate compensatory behaviors occur, on average, at least twice a week for 3 months.
- Self-evaluation is unjustifiability influenced by body shape and weight.
Binge Eating Disorder
- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- Eating, in a discrete period (e.g., within any 2-hour period), an amount of food that is larger than most people would eat in a similar period of time under similar circumstance
- The sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)
- Binge-eating episodes are associated with three (or more) of the following:
- Eating much more rapidly than normal
- Eating until feeling uncomfortably full
- Eating large amounts of food when not feeling physically hungry
- Eating alone because of being embarrassed by how much one is eating
- Feeling disgusted with oneself, depressed, or very guilty after overeating
- The binge eating is not associated with the regular use of inappropriate compensatory behavior (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.
(Note: binge eating disorder doesn’t list body image as a factor, but it is often associated with dieting and body dissatisfaction)
In each of these disorders, there is also a form of compulsive behavior, i.e calorie restriction or purging. Combined with obsessive thoughts about “eating right” or controlling body weight, the similarities between these disorders and OCD become clear.
Symptoms of Obsessive-Compulsive Disorder
OCD is a severe anxiety disorder compelling people to perform the same actions over and over again. Unless they can engage in repetitive actions and complete them to their satisfaction, people with OCD will continue feeling extreme anxiety, guilt, and panic. The anxiety level of people with OCD is so high that their compulsion to repeat actions often interferes with their ability to complete routine daily activities and maintain relationships. A few common OCD “rituals” include counting objects, stepping in and out of doorways, rearranging items, and hoarding.
Here are the DSM-5 diagnostic criteria for OCD:
- Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress.
- The thoughts, impulses, or images are not simply excessive worries about real-life problems.
- The person attempts to ignore or suppress such thoughts, impulses, or images or to neutralize them with some other thought or action.
- The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as with thought insertion).
- Repetitive behaviors (e.g., hand washing, ordering checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to the rules that must be applied rigidly.
- The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation. However, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.
Highlighting the Similarities Between OCD and Eating Disorders
Research shows that people that have an eating disorder are often co-diagnosed with obsessive-compulsive disorder. One study by Fugen Neziroglu, Ph.D., ABBP, ABPP, and Jonathan Sandler, B.A. found that between 11 and 69 percent of subjects with an eating disorder also suffered from OCD. What similarities are there that cause people with eating disorders to be more at risk for OCD and vice versa?
Eating disorders are characterized by compulsive, repetitive behaviors involving food intake. Regardless of the specific type of disordered behavior, these actions often arise from anxiety-provoking, intrusive thoughts. Unless these thoughts can be acted on, the person’s anxiety level continues to rise, affecting the person’s life and relationships. These compulsive behaviors, like withholding food, binge eating large amounts of food, and taking diuretics/laxatives to expedite the elimination of food from the body provide temporary relief from severe anxiety.
Just as people with OCD feel compelled to check, count, or wash something repeatedly, a person with an eating disorder is often obsessed with thoughts about being too fat, unattractive, and not “perfect”. Consequently, they feel compelled to follow a strict diet, constantly inspect their appearance in mirrors, and prevent weight gain through repeated disordered behaviors. These behaviors often have health consequences when left untreated; malnutrition, heart conditions, endocrine problems, and loss of bone density are not uncommon. Before some individuals can enter an eating disorder treatment center, the medical consequences of the eating disorder must be addressed in a hospital setting.
Another characteristic associating OCD with eating disorders is the sense of perfectionism, or to put it another way, a compulsion to do things a certain way with extreme anxiety resulting if they are not done that way. For example, someone with anorexia nervosa will feel extremely nervous about exceeding their (self-set) daily calorie intake. Like a person with OCD feeling distressed if they don’t perform a task the right number of times, failure to meet these “perfectionist” compulsions results in deep emotional stress. As long as they keep having obsessive, distorted thoughts about their appearance, they will be compelled to restrict their food intake.
Co-Occurring Treatment for Eating Disorders and OCD Is Available
The best eating disorder treatment program includes mental health therapy and counseling that addresses the obsessive-compulsive aspects of an eating disorder. Most eating order recovery centers provide psychiatric evaluations for all clients entering day treatment or residential treatment programs to ensure all they receive optimized individual recovery plans. A full continuum of care means treating every disorder that’s present; eating disorder therapy usually includes a psychiatrist, who will be well-versed in treating OCD as well.