By Jonathan Hoffman, PhD, Dee Franklin, PsyD, LMHC, Ciana Mickolus, PsyD, & Myriam Padron, PsyD
This article was initially published in the Winter 2022 edition of the OCD Newsletter.
Eating disorders (ED) and obsessive compulsive disorder (OCD) appear in separate chapters of the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) (American Psychiatric Association (APA), 2022) and are generally regarded as different conditions that often co-occur and share common symptoms, such as obsessional thinking, compulsions/rituals, avoidance behaviors, doubting, perfectionism, disgust, and personality factors (Palmer & Jones, 1939; Kaye et al., 2004; Simpson et al., 2013; Sternheim et al., 2017; Levinson et al., 2019; Brown et al., 2022). However, given so many shared characteristics, some researchers have believed that ED belongs in the OCD spectrum (e.g., Yaryura-Tobias and Neziroglu, 1983). We, the authors, agree and further argue from several perspectives that ED is fundamentally OCD with eating-related symptoms, focusing on factors such as feeding, shape, size, weight, and fatness.
Before diving in, we do not imply that reconsidering ED in an OCD framework would be a universal solution; even with expert treatment, there are many with OCD who make limited or no progress (Fineberg et al., 2020). Using OCD concepts and modalities would be just one component of a comprehensive ED treatment plan, just as OCD treatment is more than ERP and medication, encompassing parent and family therapy (Demaria et al., 2021), attention to sociocultural factors (Abramowitz, 2013), therapeutic skill, and other modalities. In addition, we recognize well that EDs are highly complex and heterogeneous, and that not all may neatly fit into the OCD model — differentiating which do and do not and designing effective treatments for individuals in the “gray area” between ED and OCD is a crucial clinical and research challenge. We trust it is clear that we are not advocating that anyone being treated for ED should immediately run to an OCD treatment center. Every individual experience is unique, and must be addressed with attention, care, and integrity.
Returning to the issue at hand, does it make a difference if the focus of an obsession is limited to ED characteristics (e.g., feeding, shape, size, weight, or fatness), or something like contamination, as in OCD? OCD is not defined by its obsessional content but by its process — obsessions (discomforting, unwanted and repetitive thoughts, images or sensations), compulsions (avoidance behaviors done to neutralize them), at the negative cost of these on functioning and quality of life (APA, 2022). Neuroscientific research stresses commonalities between ED and OCD (Gershkovich, Pascucci & Steinglass, 2017) but even if it did not, this type of research is not yet advanced enough to rely upon to make differential diagnoses (García-Gutiérrez et al., 2020).
When it comes to medication, considering ED and OCD as separate diagnoses might be appropriate if high-dose selective serotonin reuptake inhibitors (SSRIs) — the first-line medication for OCD — were ineffective for ED.To our current knowledge, we just do not have any studies to determine this precisely. Perhaps because it is not thought of as OCD, the eating-related obsessions of ED are often not treated with high-dose SSRIs. Yet, in one review, 4 out of 9 guidelines for the treatment of ED consistently recommended the cautious use of antipsychotics (a different class of medication not used as a primary OCD treatment) for treating obsessional thinking in patients with anorexia nervosa (Hilbert et al., 2017). OCD specialist Steven Poskar, MD, notes that if ED is a form of OCD, targeting eating-related obsessional thinking with antipsychotic monotherapy would not be indicated. He adds that in treatment-resistant OCD, low-dose antipsychotics are only used to modify high-dose SSRIs but are never used on their own (Personal Communication, September 2022). On a related note, a lack of response to high-dose SSRIs would technically not disqualify ED from being classified as an OCD spectrum disorder; excoriation disorder (skin picking) and trichotillomania (hair pulling) are related disorders for which high-dose SSRIs lack efficacy evidence (Grant & Chamberlain, 2015).
Some argue that ED is different from OCD because it is more related to sociocultural pressures, primarily on girls and women (Anderson-Fye & Becker, 2004). This argument is problematic because the notion that ED is caused by as opposed to influenced by these pressures is scientifically inaccurate, and OCD can be influenced by sociocultural factors such as religion (Nicolini et al., 2017). ED was also present in past societies lacking contemporary pressures regarding weight; a connection between ED and sociocultural factors was not made until a few decades ago (Shambag, 2020). From our view, utilizing a feminist perspective as a treatment modality for eating-related obsessions and rituals (Holmes et al., 2017; Maine & Samuels, 2017) would only make sense if particularly deemed relevant in a specific case presentation and not as a substitute for evidence-based treatments (EBT).
Does ED’s association with trauma and posttraumatic stress disorder (PTSD) (Vanzhula at al., 2019) differentiate it from OCD? We do not think so. Trauma and PTSD are also found in OCD (Dykshorn, 2014). Similarly, while many individuals with ED have problems with emotional regulation (Thompson-Brenner et al., 2018; Lappanen et al., 2022), Vahidpour (2022) noted that difficulties in emotional regulation are present in OCD.
ED is associated with an array of medical risks such as malnutrition and bone damage, as well as a high rate of mortality compared to other psychological disorders (van Hoeken & Hoek, 2020). This should not serve as an obstacle to conceptualizing ED as a manifestation of OCD because of these risk factors and the specific treatments to address them (e.g., nutritional guidance, refeeding). Medical risks are found throughout psychological conditions (Monen et al., 2020) and in OCD specifically (Witthaur at al., 2014). Although suicidal risk is the second leading cause of death in ED (Smith, Zuromski, & Dodd, 2018), this risk is also present in OCD (Bowen et al., 2021).
Level of insight does not distinguish ED from OCD. People vary in and toggle back and forth in the level of insight whether diagnosed with ED (Kostantakopolos et al., 2011) or OCD (de Avila et al., 2019) due to a variety of circumstances ranging from what symptom and stress triggers they are presently experiencing to cultural pressures. In some severe cases of ED, loss of insight may be a medical consequence of being cognitively compromised due to caloric restriction and weight loss, not a distinct factor that conceptually sets it apart from OCD (Guarda, 2015). For those who may think that ED is different because some patients glorify their symptoms, we offer this response: we suspect that many OCD clinicians treat individuals who may also glorify certain OCD symptoms, viewing them as having superior or special knowledge.
As the tables below illustrate, when we translated the DSM-5-TR (APA, 2022) criteria for all the current diagnoses within the ED category into diagnostic language used for OCD, ED appears to match up very well with OCD. (Please note that these tables do not include diagnoses such as orthorexia, diabulimia, exercise bulimia, and other similar conditions; although they are valid conditions, they are not presented in the DSM-5-TR.)
Anorexia Nervosa
| Diagnostic Criteria | OCD Language |
| Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as weight that is less than minimally normal or, for children and adolescents, less than minimally expected. | Obsessions about the correct amount/types of food, relative to a standard or a set of rules determined by the individual
Avoidance of food
Consequences of avoidance |
| Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. | Obsessions related to just-right appearance or
number. Obsessions about symmetry, perfection, a kind of nutritional scrupulosity. Disgust and fear regarding weight, fat, or a number outside of perfection or just-right range. Compulsions to prevent weight gain/fatness/sustain low weight. Compulsions to maintain and sustain a just-right appearance of particular body parts. |
| Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. | Obsessions related to appearance, just right feelings, perfectionism, overvalued ideation.
Pathological disgust followed by compulsive attempts to neutralize it with ritualized behaviors such as exercise, vomiting, and enema.
Poor insight. |
| Restricting type: During the last three months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is done primarily through dieting, fasting, and/or excessive exercise. | Avoidance of food due to obsessions about the effects of certain food types/ amounts on the body.
A kind of nutritional scrupulosity about the frugality of limited eating. Compulsive self-limiting related to just-right feelings of control, purity, frugality, cleanliness, or emptiness.
Compulsive behavior (restricting, dieting, exercise). |
| Binge-eating/purging type: During the last three months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). | Compulsive behavior.
Pathological disgust and fear followed by compulsive attempts to neutralize with ritualized compensatory behaviors such as exercise, vomiting, and enema. |
Bulimia Nervosa
| Diagnostic Criteria | OCD Language |
| Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: | Compulsive/impulsive behavior to minimize distress caused by an internal or external trigger. |
| Eating, in a discrete period of time (e.g., within any two-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances. | Compulsive behavior (often carefully planned and ritualistic, but sometimes compulsive) aimed at alleviating experiential distress. |
| A 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). | Disgust, distress, fear of weight gain. |
| Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise. | Pathological disgust followed by compulsive attempts to neutralize resulting distress with ritualized compensatory behaviors. |
| The binge eating and inappropriate compensatory behaviors both occur, on average, at least one week for three months. | N/A |
| Self-evaluation is unduly influenced by body shape and weight. | Obsessions related to body shape, weight, and size. |
| The disturbance does not occur exclusively during episodes of anorexia nervosa. | N/A |
Binge-eating Disorder
| Diagnostic Criteria | OCD Language |
| Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: | Compulsive behavior |
| Eating, in a discrete period of time (e.g., within any two-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances. | Compulsive behavior to minimize situational distress. |
| A 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). | Compulsivity with a corresponding difficulty in harnessing these responses. |
| The 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 feeling embarrassed by how much one is eating. Feeling disgusted with oneself, depressed, or very guilty afterward. |
Compulsive behavior does not represent normal eating behaviors, natural physiological needs and limits.
Compulsive behavior as avoidance of distress and discomfort.
|
| Marked distress regarding binge eating is present. | Distress |
| The binge eating occurs, on average, at least once a week for three months. | N/A |
| Binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa. | N/A |
Avoidant/Restrictive Food Intake Disorder (ARFID)
| Diagnostic Criteria | OCD Language |
| An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) associated with one (or more) of the following: | Obsessions related to eating only preferred foods (regardless of availability) and complete avoidance of all other foods due to pathological disgust
Tendency to eat food that involves just-right obsessions, sensory issues, or fear of harm.
Avoidance of food related to beliefs about feared outcomes (nausea, pain, disgust) |
| Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
Significant nutritional deficiency. Dependence on enteral feeding or oral nutritional supplements. Marked interference with psychosocial functioning. |
Consequences of avoidance |
| The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice. | N/A |
| The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced. | N/A |
| The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and calls for added clinical attention. | N/A |
Pica
| Diagnostic Criteria | OCD Language |
| Persistent eating of nonnutritive nonfood substances over a period of at least 1 month. | Compulsive behavior
|
| The eating of nonnutritive, nonfood substances is inappropriate to the developmental level. | N/A |
| The eating behavior is not a part of a culturally supported or socially normative practice. | Compulsions are generally not culturally/socially normative |
| If eating behavior occurs in the context of another mental disorder […], it is severe enough to call for further attention. | N/A |
Rumination Disorder
| Diagnostic Criteria | OCD Language |
| Repeated regurgitation of food over a period of at least 1 month. Regurgitated food may be re-chewed, re-swallowed, or spit out. | Obsessions regarding sensory challenges (e.g., textures), choking, swallowing sensations.
Ritualized and compulsive eating behaviors (e.g., “food rules”) |
| The repeated regurgitation is not attributable to an associated gastrointestinal or other medical condition […]. | N/A |
| The eating disturbance does not occur exclusively during the course of [another eating disorder]. | N/A |
| If in the context of another mental disorder […], they are sufficiently severe to warrant additional clinical attention. | N/A |
Although OCD has not been of much interest in ED treatment centers in the past, the landscape seems to be changing. Exposure-based therapies adapted from OCD and anxiety treatment are now featured in some ED treatment facilities and studies (Reilly et al., 2017; Thompson-Brenner et al., 2018; Butler & Heimberg, 2020). Is this an implicit recognition of the pertinence of OCD to ED? We hope this pattern continues, as the prevalence and toll of eating-related symptoms on individuals, families and society is high (Streatfeild et al., 2021).
Now, let’s consider why ED might not be OCD. Equating the ED focus on body image (Miyake et al., 2010) with OCD’s fear/anxiety-based obsessions is complicated. Some research suggests that individuals with anorexia nervosa have perceptive body distortions (e.g., Dalhoff et al., 2019) like those associated with body dysmorphic disorder (BDD) (Wong et al., 2022), corresponding to body-related self-critical cognitions or mental models. However, how much of the body image focus and dissatisfaction in ED is a form of just-right experience OCD? Perhaps it is also true that obsessive body image concerns, and rituals surrounding them, do not have a degree of fear/anxiety associated with them, but that the driving factor is disgust — a factor that plays a role in some forms of OCD (Bhikram, Abi-Jaoude & Sandor, 2017). Persistent qualities of contemporary culture (such as “selfie culture”) further complicate a solid clinical understanding.
Another point about ED being its own category relates to the role of negative reinforcement — are ED rituals (e.g., counting calories, checking food labels, ordering and arranging in food preparation) driven by it as much as OCD compulsions? Walsh (2013) attributed the persistence of anorexia nervosa more to initial positive reinforcement for weight loss followed by habit formation, like in an addiction. However, following this train of thought, while positive reinforcement followed by habit formation characterizes the early stages of addiction, negative reinforcement plays a role as well: over time the addiction often shifts from seeking the “high” to avoiding the “low” (e.g., Baker et al., 2004). We should also consider experiential avoidance (seeking to not have distressing thoughts, feelings, memories or sensations) in ED, or negatively reinforcing behavior that corresponds to avoidance in OCD (Espel-Huynh et al., 2019). Future research is needed for a more definitive understanding and comparison between ED rituals and OCD compulsions.
Finally, some therapists believe that individuals with ED can “grow out of it,” whereas those with OCD do not. From our experience as clinicians, we do see that some people with ED report that their symptoms resolve with maturation, but with the following caveat: For many individuals with ED whose primary/severe symptoms are resolved, subclinical worries about food (such as in orthorexia) or “white knuckling” through triggering situations can persist. Some have simply learned how to be more secretive. Anecdotally, we have had clients with OCD who were earlier diagnosed with ED but no longer had eating-related symptoms; they seemed to think less that they had grown out of ED and more that their obsessional focus had shifted over time.
Nonetheless, we advocate thinking more about ED from an OCD perspective. Whether ED is ever reclassified as OCD or a related disorder in the DSM awaits future research, but the evidence is hard to ignore. In any event, placing eating-related symptoms in an OCD framework could serve to:
- Spur more thorough assessment of OCD symptoms in patients with eating-related problems, and promote the use of EBTs, such as exposure and response prevention (ERP), the gold standard treatment for OCD (Hezel & Simpson, 2019). There may be modifications of ERP that are necessary to make to effectively treat eating-related OCD symptoms. Those for whom ERP is not effective may benefit from other OCD treatment modalities such as acceptance and commitment therapy (ACT) (Soondrum et al., 2022).
- Focus more on reducing ED-associated rituals/compulsions and avoidance behaviors as the primary treatment targets, as well as increasing tolerance of distress and uncertainty, instead of trying to stop or “explain” obsessions — all established recommendations for OCD.
- Better inform medication selection and dosage for targeting eating-related obsessive and compulsive symptoms (e.g., high-dose SSRIs) and, encourage relevant research.
We hope that this article stimulates further discussion and sharing of ideas among ED and OCD practitioners. It would be interesting to collect data from individuals who have had both ED and OCD and see how similar they think they are and investigate whether using an OCD framework in an early intervention protocol for eating-related symptoms would improve outcomes.
We would like to end this by referencing a saying: “If it looks like a duck, and quacks like a duck, then it probably is a duck.” When it comes to ED and OCD, there are quacking sounds that need to be reckoned with more fully.
ACKNOWLEDGMENTS:
The authors would like to thank Dr. Steven Poskar, Dr. Jon Abramowitz, Dr. Brad Reimann, Ms. Susan Boaz and Dr. Katia Moritz for their thoughtful feedback during the writing of this article.
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