The Crossover Between Obsessive Compulsive Disorder and Eating Disorder

            Clients presenting with symptoms of obsessive, rigid thinking along with patterns of over-eating or under-eating may be struggling with the presence of both Obsessive Compulsive Disorder (OCD) and Eating Disorder (ED). These two disorders have a lot of similarities to one another when it comes to symptoms and treatment, however they do need to be treated separately. The goal of this article is to shed light on the conversation to aid in more effective treatment outcomes. Specifically, we will be talking about having a team approach to treatment while being cautious of assumptions about treating similar presenting symptoms as the same disorder.

Obsessive Compulsive Disorder and Eating Disorder

Obsessing and engaging in compulsions can be expressed in several forms. The point at which those behaviors can be classified as OCD is when there is marked distress caused by repetitive and unwanted thoughts, feelings, mental images, or physical sensations that are alleviated by participating in reassurance seeking, repetitive behaviors, or avoidance. OCD is an ego-dystonic form of thinking, meaning the person’s thoughts are coming from a fear that they do not ever want to face because it is inconsistent with their values.

The OCD Cycle. External and interanl triggers cause an obsession. OCD Obsessions are often "what if" or "if, then" questions that cause anxiety, which is often that "Oh No" feeling. To get rid of the anxiety, rituals, avoidances, reassurances, or checking compulsions are done. This provides relief and confidence, but is often short lived and the obsession returns. Thus, completing the OCD cycle by starting from the top again.

Eating Disorders can include a spectrum of restrictive eating and binge eating and appear to have a similar behavioral pattern as those with addictive disorders. ED’s are ego-syntonic as their overwhelming thoughts support their personal goals, values, and beliefs. Eating Disorders are one of the many co-occurring disorders that align with OCD and can be defined as a condition that creates a disturbance in eating behaviors and is associated with distressing thoughts and emotions.

Identifying Symptoms & Treatment Protocol

Even though they may have a lot of similar behaviors, if your client is exhibiting both OCD and ED symptoms a treatment team is recommended so that each diagnosis is treated individually. If you specialize in treating one of these disorders, it is ethical to advise your client to seek additional support for their co-occurring disorder by offering them proper referrals. This can sometimes be a challenge for clients as they may be hesitant to start over with a new therapist or may not have the financial means. It is wise as a clinician to remind your client that they can advocate for themselves at this time so that they can experience quality support for all of their needs.

The best-case scenario would be to find a therapist who treats OCD, another one who treats the ED, and a nutritionist who is educated on both disorders if both OCD and ED are present. It is important to remind your client that they cannot assume that one clinician can treat all of their symptoms with all of the different forms of thinking at play.

Now, let’s dive a little deeper into the type of care each of these specialists can provide.

Nutrition Treatment

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Professional collaboration between your various treatment teams often lead to the best outcomes

A nutritionist may be needed to assist a client to get back on a proper feeding and dietary care regimen. This is done by evaluating the current eating schedule for gaps or deficiencies in food intake and designing a plan to achieve a nutritional balance that supports mental and physical health. If a nutritionist is not on the same team as the OCD and ED treatment providers, they might misunderstand their patient by disregarding their feared thoughts associated with OCD and ED. Therefore, a team approach is necessary with both OCD and ED clinicians to work up a client’s various hierarchies to see what they are open to introducing back into their eating.

It is advisable to have the entire team address symptom presentation first. If a client is not able to learn new techniques or focus in therapy because of the brain fog from not eating sufficiently, a nutritionist will need to step in for emergency purposes to find creative ways to help their client’s body get fueled enough to work through their obsessive thoughts and compulsive behaviors with their therapist(s).

Re-Feeding Syndrome can be present if a patient’s ED symptoms persisted to a stage of malnourishment. Re-Feeding Syndrome is a serious and potentially fatal condition that can occur when there are sudden shifts in the electrolytes the body uses to metabolize food intake. This condition can slow down the process of therapeutic modalities of treatment because several deficiencies may be present and need to be worked with at a cautious pace. If your client is presenting with fatigue, weakness, confusion, high blood pressure, seizures, or heart complications while in session these would be signs to speak with a local doctor immediately for a transition of care.

OCD Treatment

Treatment for OCD will focus on helping a client to tolerate uncertainty while also learning to cope with stigma and shame. Examples of OCD symptoms with an ED crossover can be seen in contamination-themed obsessions and Emetophobia (fear of vomiting). Someone struggling with contamination obsessions could be avoiding eating food due to the fear of food poisoning or allergic reaction. These individuals could have an extremely restrictive menu because they might only feel okay eating foods that they historically know have been “safe” and have not caused them harm internally or externally. Clients with Emetophobia may also restrict their food intake for the fear of throwing up. They might stick to plain foods or plan not to eat during or around times where they may be experiencing motion, such as driving, flying, or riding roller coasters.

Two people sitting across from one another in a therapy session
Therapy can be difficult, but a compassionate, understanding therapist can help you take steps toward recovery.

 OCD symptoms patient will be addressed through Cognitive Behavioral Therapy (CBT), Exposure and Response Prevention (ERP), and Acceptance and Commitment Therapy (ACT).

Eating Disorder Treatment

            Eating Disorder treatment will have a greater emphasis on creating a peaceful relationship with food, their body, and how their body moves. ED symptoms, such as negative core beliefs about diet culture and sizeism, will also be addressed through CBT or CBT-E. CBT-E, or Enhanced Cognitive Behavioral Therapy, is a program that follows four stages to guide an ED client on the path to recovery. Along the process, the stages will address gaining an understanding of the disorder, helping to stabilize eating behaviors, looking at what maintains the eating behaviors, how to cope with day-to-day events or moods that get triggered, working towards a future mindset, and how to deal with setbacks that may come their way.

For patients who are underweight there will be a need for a weight regain process that incorporates CBT-E. This process will rely on the patient’s willingness for change so that they have full autonomy over their body and recognition of their realistic treatment goals. Forcing weight gain on someone in this position only causes more stress to their mind and body so the re-fueling process needs to be addressed delicately.

Further, it is advised to focus on how these clients can be open to being size inclusive and rejecting diet culture because they will learn to see that all foods fit for their body. Another restructure that can be shared with clients is trying to look at food as neutral and not seeing one food group as healthy and another as unhealthy.

Intuitive Eating is an additional technique that helps clients to learn to eat with purpose. In this method, people become more in tune with their biological mechanisms by learning how their body sends them signals when it is time to eat and when they are full. A growing awareness of their body’s natural cues can help people to be able to notice when their body is under distress and how they can challenge themselves to push through that discomfort and apply self-care as needed. Educating clients on how to listen to their body and notice the differences between hunger, fullness, and what their appetite feels like will help to repair the bond between themselves and their eating behaviors.

ERP & Safety Behaviors

Sheet of paper with an empty "to-do" list of the day.
Being intentional about therapy through daily planning can help to keep you on track toward your treatment goals.

Exposure and Response Prevention (ERP) is recommended for both OCD & ED treatment. However, ERP is going to be separate for an individual who presents with both OCD and ED symptoms. Clients build two treatment hierarchies so they can expose themselves to the range of their core fears; one for OCD and other for ED. It is important to assess the details behind one’s core fears to see what their intentions are, the purpose of their behaviors, sources of their uncertainty and avoidance, and what brings them their desired relief.

For ED symptoms the hierarchy will build around food and body exposures. There may be many differing levels of comfort present so the client can acknowledge that they will need to challenge themselves on some days and take it easy on others. This could look like having set days of the week where a client is willing to try unsafe foods and others where they can only imagine eating safer options through interoceptive work.

Clients presenting with OCD will be structuring their hierarchy around internal and external triggers. These will all have a feared story and associated compulsions to avoid their perceived worst-case scenarios. In one case, a helpful starting point may be to write a triggering word several times or practice using it in a non-threatening sentence. Building on this, a client can choose to work through imaginal exposure, which is an exercise where they imagine what it would be like and what it would feel like to have their worst-case scenario come true.

It is wise to also organize chosen exposure exercises into a homework chart so that the client has a clear visual of what days they can mark as completed or when they did not hit the mark with their assigned exposures. Creating an area on the chart that provides reminders or special considerations to remember when participating in an exposure exercise at home can also be helpful. Clients may fill in that area with words of encouragement for themselves, or prompts to use grounding or deep breathing before, during, or after doing an exposure.

Two people walking down a hall referencing a clipboard
Collaborating with treatment providers who specialize in Eating Disorder and OCD can help you reach your treatment goals.

Exposure work will elicit more anxiety, so check in with your client often to make sure they feel ready to challenge themselves so that they feel supported at their pace. Another item to look out for is if your client starts developing new compulsive safety behaviors while doing ERP. Slowing down treatment can be beneficial so that the client can be more aware of what is a safety behavior versus what a healthy coping mechanism looks like to offer perspective and insight. Common safety behaviors appear as avoidance, distraction, preparing, checking, and can turn into repetitive rituals for clients with OCD and ED.

If you are treating someone who has been struggling with OCD, ED, or a combination of the two, getting them the right help is crucial to seeing positive change. Even when it feels like you have hit a wall with them, know that there is a team out there that is waiting to assist you and your client to work through the sticking points that you may have not been aware of if you are not used to treating both disorders. Sometimes all it takes is finding the right information at the right time to see a different perspective of what it looks like to help your clients repair the relationship they have with their mind and body.

Further resources about OCD and ED can be found on the International OCD Foundation & the National Eating Disorder Association websites:

Written by Shannon Prebil, AMFT

If you, or someone you know, is struggling at the intersection of Obsessive Compulsive Disorder (OCD) and Eating Disorder (ED), treatment is available. For more information about treatment for OCD and ED with The California OCD and Anxiety Treatment Center through online teletherapy or in-person therapy, please contact us here, or call us at (714) 423-3779.

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