Obsessive-compulsive disorder (OCD) and eating disorders, including those related to weight loss, often share a complex and intertwined relationship. OCD, characterized by uncontrollable obsessions and compulsions, can significantly influence eating disorder behaviors, and vice versa. This article explores the intricate connections between OCD and weight loss, shedding light on how these conditions can co-occur, influence each other, and how comprehensive treatment approaches can effectively address both.
Understanding OCD and its Manifestations
Obsessive-compulsive disorder (OCD) is an anxiety-inducing condition featuring patterns of intrusive, unwanted thoughts (obsessions) that lead individuals to perform repetitive behaviors (compulsions). OCD affects individuals of all ages, disrupting daily functioning and social interactions.
Obsessions can be defined as intrusive, unwanted urges or thoughts that can trigger feelings that are distressing. In attempt to manage these feelings or decrease distress, a person with OCD will engage in compulsive behaviors, which are typically repetitive and done with the intention of countering an obsession. Some of the most common obsessions related to OCD include unwanted sexual thoughts, fear of contamination and/or illness, losing control, fear of harming others or oneself, and obsessions related to perfectionism. Common compulsive behaviors that are often engaged in as an effort to counter these types of obsessions include repeated checking, excessive washing and cleaning, mental compulsions, and repeating activities in multiples.
OCD is typically diagnosed when an individual is consumed with these recurring obsessions/compulsions to the point that overall quality of life is compromised and/or a person becomes unable to function in daily life. According to the International OCD Foundation, about 1 in 100 adults, or between 2 to 3 million adults, in the United States alone currently has OCD, with at least 1 in 200 kids and teenagers having OCD.
Eating Disorders: A Multifaceted Mental Illness
Eating disorders are complex, multifaceted brain disorders rooted in biological, psychological, and social risk factors and triggers. These disorders are associated with several behaviors that are ritualistic by nature and which mirror those of OCD. Many individuals with eating disorders experience thoughts and behaviors around food and their bodies that are rigid by nature, often triggering complex and recurring patterns that can result in detrimental consequences.
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The Comorbidity of OCD and Eating Disorders
There is a high rate of comorbidity between eating disorders and OCD. Research has identified a strong correlation between obsessive compulsive disorder and eating disorders, with one study demonstrating that 41 percent of individuals with eating disorders were found to have OCD.
There can be many similarities in how OCD and eating disorders present. For example, both OCD and eating disorders may be characterized by obsessive, distressing thoughts. Eating disorders and OCD tend to share other common characteristics as well, like repetitive or compulsive behaviors. For those with an eating disorder, the behaviors may include ritualistic eating behaviors, exercising, or purging. And for those with OCD, there’s a range of compulsive behaviors that may be present.
Eating disorders and OCD are both marked by cognitive inflexibility and challenges with set-shifting, the ability to move back and forward between different tasks or mental sets. Some researchers suggest that certain personality traits and cognitive styles may increase vulnerability to both OCD and eating disorders, which may explain why there’s such an overlap between the two. Perfectionism, for example, is one trait that has been found to be associated with both eating disorders and OCD. Perfectionism refers to the drive to meet a high standard, being highly critical of oneself, and experiencing significant distress in response to perceived failure.
How OCD Can Fuel Eating Disorders Focused on Weight Loss
For some people with eating disorders, obsessive thoughts around food, weight, or body size may lead to levels of anxiety that can only be quelled by compulsive behaviors, like restriction, purging, over-exercise, and more.
Lauren Gerber says she always considered herself to be a fairly obsessive person. But she never identified as someone with obsessive-compulsive disorder (OCD), a mental illness characterized by uncontrollable and recurring thoughts (obsessions), repetitive behaviors (compulsions), or both. She was also never formally diagnosed with the condition-until 15 years after she’d recovered from her eating disorder. “Looking back, I believe OCD absolutely helped fan the flame for my eating disorder,” Gerber says. “I remember not being particularly mentally interested in food or my body or dieting during my eating disorder. I was instead absolutely fixated on the number on my scale-specifically it being an even, flat number-or a precise ratio of certain ingredients.
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OCD that focuses on symmetry and order can also contribute to an eating disorder, as this type of OCD involves obsessions over numbers and counting. For example, a person with obsessive thoughts concerning weight gain may engage in eating disorder behaviors as a means of countering the resulting anxiety, including extreme dietary restrictions, purging, bingeing, over-exercising, food rituals and more. When it comes to eating disorders and OCD, the primary obsessive thoughts and compulsive behaviors are surrounding body size, weight, perfectionistic eating habits and the like.
The Vicious Cycle: Disordered Eating, Weight Loss, and OCD Symptoms
Even though obsessions and compulsions around food or weight may not merit an OCD diagnosis if those behaviors are all associated with an eating disorder, it’s important to note that low weight and malnutrition can actually increase obsessive-compulsive symptoms. This triggers what Luo calls a “vicious cycle” that starts with disordered eating behaviors leading to weight loss. This doesn’t mean that OCD causes eating disorders, but rather indicates how the former might come before the latter in a person who is genetically vulnerable to both disorders.
ARFID, Food Aversion, and OCD
Someone with food aversion, or ARFID, will avoid foods because they find them to be unappealing or because they are worried about the consequences of eating. What is different between this condition and other eating disorders like AN is that a person with ARFID does not have a concern or fixation with their weight or body shape. In fact, a person with ARFID may desire to eat properly and gain weight, but their food aversions prevent them from doing so.
Some people may have food aversion because of their OCD, while others may have OCD symptoms as a result of their food aversion. A person with food aversion and OCD may obsessively avoid certain foods or obsessively overeat only a few specific types of foods because they are attempting to avoid unpleasant symptoms like upset stomach, allergic reactions, or difficulty swallowing.
While someone with ARFID may be obsessive about avoiding eating food, sometimes a person experiences both ARFID and OCD. In some cases, the two disorders can appear similar, but when someone has both conditions, they will meet the distinct diagnostic criteria for each disorder. A person with OCD experiences obsessive thoughts and mental images and engages in compulsions, which are behaviors or rituals meant to cope with the obsessive thoughts. Someone who has both ARFID and OCD may have intrusive thoughts about contamination, and they may avoid certain foods, or perhaps all foods, out of fear of eating something that is contaminated. There is evidence that ARFID and OCD can occur together. In a study involving 90 individuals with ARFID, 6.1% also had an OCD diagnosis.
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If a person has a fear of becoming ill from eating certain foods, their appetite may be diminished. Perhaps they also develop obsessive or intrusive thoughts in response to a worry that they will throw up or develop a stomach ache in response to eating. In this case, OCD could also reduce appetite.
Orthorexia Nervosa: When Healthy Eating Becomes an Obsession
Healthy eating is important for overall wellness. But individuals who hyperfocus on clean or super-healthy foods may develop Orthorexia Nervosa (ON), a condition based on anxiety-provoking, restrictive eating patterns. Though the emerging condition has not been formally recognized by the American Psychiatric Association’s (APA’s) official disorders manual, it has recently gotten more attention in research studies.
Orthorexia Nervosa (ON) is a condition centered on healthy eating where individuals feel excessive emotional distress from food choices perceived as unhealthy. This distress may lead to restrictive eating that causes unintended weight loss, malnourishment, and problems with relationships.
Individuals with orthorexia obsessively think about healthy food, food planning, and the associated rituals. The obsessions are intrusive and disruptive, evoking anxiety and negatively affecting quality of life. Much like compulsive behavior patterns associated with OCD, individuals with orthorexia may develop rigid rituals for meal prep and planning to preserve the purity of their food. Ensuring the perfect preparation of food may become time consuming, especially when these patterns involve specific utensils and procedures. Failure to strictly follow these or other rules about their diet can be perceived as a threat to their health.
One significant difference between orthorexia and OCD is how individuals perceive their symptoms. As is the case with anorexia nervosa, individuals with orthorexia strive toward perfect performance of their compulsive behaviors, even though they are a critical element of their disorder. A comparison between orthorexia and OCD reveals important connections, including irregularities in brain functioning, obsessive thought content, and compulsive behaviors.
The Importance of Accurate Diagnosis
In order to properly diagnose and treat people, it’s critical for providers to assess the nature and timeline of the onset of obsessive-compulsive behaviors, as well as those of the eating disorder and any weight loss.
While OCD and eating disorders can co-occur, it’s not uncommon for people with eating disorders to demonstrate obsessive-compulsive behaviors in the absence of true clinical OCD. That is, someone who is struggling with an eating disorder may have many distressing obsessions about food, weight, and their body, and they may engage in ritualistic or compulsive eating-related behaviors.
Comprehensive Treatment Approaches
Just as eating disorder treatment requires a multidisciplinary approach, OCD may also require various forms of therapy, medications, or both to address and manage symptoms. When a person lives with food aversion, OCD, and eating disorders, treatment is often necessary to restore health and well-being. OCD symptoms create significant distress and can interfere with a person’s functioning at school, work, or in relationships. ARFID often results in health problems, as it is linked to weight loss and nutritional deficiencies.
There isn’t strong evidence to support the use of just one treatment modality for both diagnoses. However, Cognitive behavioral therapy (CBT) principles can be effective for both, although the specific applications will vary. The absence of one standard treatment protocol to address both disorders at once doesn’t mean that they can’t be treated effectively at the same time. While CBT and ERP share the same underlying principles and thus work well together, other treatment modalities can also be successful in treating OCD and eating disorders together. Even if a treatment other than CBT is being used to treat the eating disorder-say, family-based treatment (FBT)-it’s still possible to introduce ERP alongside that treatment.
Psychotherapy
Psychotherapy is also used to treat obsessive compulsive disorder and any existing anxiety disorders. A specific type of treatment called cognitive behavioral therapy (CBT) can be especially helpful, as it can teach individuals with OCD to overcome obsessive thoughts and change their behavior in response to these thoughts. CBT can also be utilized to help individuals with ARFID overcome obsessions and fears related to food.
Noah Clyman, a licensed clinical social worker and the director of NYC Cognitive Therapy, a private psychotherapy practice in New York City, says that exposure therapy can help people who have OCD find a way to understand and then relinquish the habits that disrupt their daily lives. “I tell patients that when they confront situations that cause them distress, and they stay in the situation for long enough without escaping or doing rituals, they’ll learn several things,” he says. “They’ll learn that the anxiety does not last forever. In fact, it decreases even without escaping, avoiding, or ritualizing. Also, they’ll find out that as their anxiety decreases, their urge to ritualize and to escape from the situation also decreases.”
Research shows that a type of cognitive behavior therapy (CBT) called Exposure and Response Prevention (ERP), or spending time in the situation that triggers your compulsions (such as touching dirty objects) but then not performing the usual resulting compulsion (such as hand-washing), effectively reduces compulsive behaviors in OCD.
Medication Options
Although therapy is the treatment of choice for OCD, some people who have a severe form, or do not respond to therapy, may use medications to help with the disorder. Medications used to treat OCD include:
- Serotonin Reuptake Inhibitors (SRIs): Serotonin reuptake inhibitors (SRIs), which include selective serotonin reuptake inhibitors (SSRIs), are used to help reduce OCD symptoms.
- Antipsychotic Medication: If your symptoms don’t improve with SRIs, research shows that some people who have OCD may find some relief with an antipsychotic medication.
However, research suggests that medications for OCD are only partially effective. “Cognitive behavioral therapy, using the techniques of Exposure and Response Prevention, have the best and most consistent research support for OCD,” says Dr. Abramowitz.
Alternative and Complementary Therapies
The FDA approved transcranial magnetic stimulation (TMS) in 2018 as a supplementary treatment for OCD in adults. TMS is a noninvasive procedure in which an electromagnetic coil is placed against your scalp near your forehead. The electromagnet uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of OCD. The FDA approved a device, BrainsWay Deep Transcranial Magnetic Stimulation, to treat OCD in adults when traditional treatments have not been effective.
Deep brain stimulation (DBS) may help the 10 percent of people who have treatment-resistant OCD. DBS is approved by the FDA to treat OCD in adults who don’t respond to traditional treatment methods. With DBS, electrodes are implanted within certain areas of the brain.
Responsive Feeding Therapy
Those with ARFID, specifically children, may also benefit from responsive feeding therapy (RFT). This involves the individual’s parent or caregiver ensuring mealtime routines are present and coupled with pleasant interactions.
Seeking Comprehensive Care
If you have struggled with OCD and a resulting eating disorder, you have undoubtedly faced the chaos, stress, and overwhelm that comes with these co-occurring mental health issues. Perhaps you have sought help for an eating disorder or OCD but felt like you have been unable to find a resolution to these connected issues. Because OCD and eating disorders are often comorbid conditions, effective treatment options should include a multidisciplinary approach that offers extensive therapy, medication management, medical nutrition therapy, and more.
When a person has co-occurring conditions like an eating disorder and OCD, it is important to receive comprehensive, integrated treatment to address both conditions. If the OCD is left untreated, for example, the eating disorder may persist. Treatment for ARFID or food aversion with OCD often involves mental health care to address the underlying anxiety surrounding food or negative reactions to food consumption. Many patients must also work with a dietitian to develop an appropriate meal plan that provides adequate nutrition.
Integrating evidenced-based treatment approaches for OCD, like Exposure and Response Prevention Therapy, Cognitive Behavioral Therapy, and medication with traditional eating disorder treatment may be helpful in addressing the co-occurring conditions. Connecting to a specialist is the first step toward treating the complex issue of co-occurring OCD and eating disorders. Ultimately, the best course of treatment for a patient with ARFID and OCD will depend upon their unique needs. If you’re living with obsessions surrounding food, it is important to reach out to mental health professionals or a treatment center. A team of qualified professionals can help you to identify the root causes of your fears around food and develop a treatment plan that addresses your disordered eating.