Many people who suffer from eating disorders such as anorexia nervosa, bulimia nervosa, and binge eating disorder also suffer from other conditions. These can include, but are not limited to, depression, generalized anxiety disorder, post-traumatic stress disorder, and obsessive-compulsive disorder.
Approximately two-thirds of people with eating disorders also suffer from an anxiety disorder; the most common is believed to be obsessive-compulsive disorder (OCD). Some studies have shown that, in women with anorexia nervosa, the rate of OCD is between 25% and 69%, and for women with bulimia nervosa, it's between 25% and 36%.
What is obsessive-compulsive disorder?
As its name implies, people who suffer from obsessive-compulsive disorder struggle with either obsessions or compulsions.
Obsessions are recurrent and frequent thoughts or impulses that are experienced as intrusive and inappropriate, and can cause distress and anxiety. These thoughts are not simply worries about real-life problems, but the person does recognize these thoughts as products of his or her mind, and will attempt to ignore, suppress or stop the thoughts by doing some other action or thought.
Compulsions are repetitive behaviors or mental acts that are performed in response to an obsession. Common compulsions are acts such as hand washing, repeated checking (to see if the door is locked or an appliance is turned off, for example), praying, counting, or repeating words. Although the goal of these acts is to reduce anxiety and worry, they are excessive.
The persons suffering from these obsessions and compulsions may be aware that the thoughts and actions are excessive and unreasonable. However, the obsessions and compulsions continue to cause distress and take up significant portions of time. This disrupts the sufferer's normal routine and can cause problems in work, school and/or relationships.
Some of my clients have asked me: at what point does something cross the line into obsessive-compulsive behavior? There are no specific guidelines as to how often or how many times a thought or action must occur in order to be considered obsessive-compulsive, but you can ask yourself the question, "Does it get in the way of my life?" as a starting point to determine if it's an issue for you. For example, hand washing is an activity that we are encouraged to do in order to keep ourselves and others well. But when hand washing becomes so time consuming that hands begin to bleed, or that a person isn't able to participate in activities, then it has become a problem.
How does OCD relate to eating disorders?
Both people with eating disorders and people with OCD suffer from intrusive thoughts and compulsive actions. But for those people who only have an eating disorder, these obsessions and compulsions are limited to thoughts and actions related to food and/or weight. When a person with an eating disorder also has obsessions and compulsions about other areas of their lives, they may also be experiencing symptoms of OCD.
Interestingly, a 2003 research study found women who experienced OCD in childhood are at a higher risk for developing an eating disorder later in life.
How does it affect treatment?
Anytime that a person is experiencing symptoms of multiple disorders, it can complicate treatment. Fortunately, there are effective treatments for both eating disorders and OCD. Obsessive-compulsive disorder is typically treated by medication and/or psychotherapy.
Cognitive-behavioral therapy (CBT) has been found to be an effective treatment for both OCD and for eating disorders. In CBT, clients are taught how to recognize negative or intrusive thoughts, and then change how they react or respond to them.
Exposure and response prevention (ERP) is another type of psychotherapy that has been shown to be effective at treating OCD. As its name implies, a therapist using ERP will expose the client to anxiety or obsession-inducing situations, and then work with the client to prevent them from engaging in any type of compulsive behavior. For instance, if the person is struggling with hand washing, an ERP therapist may work with the client to go through extended periods of time without washing his hands at all, or to use the restroom and then leave without washing his hands.
This is actually very similar to what many people go through in the treatment and recovery from their eating disorders as well. For example, someone with anorexia or bulimia experiences a great deal of anxiety when he/she eats a meal. Although he/she may have urges to exercise, purge or restrict after a meal, the treatment team is working with him/her to prevent these from occurring. In a higher level of care, such as inpatient hospitalization or residential treatment, he/she may be physically prevented from acting upon those urges.
Fortunately, many therapists who work with eating disorders are familiar with the treatment of other disorders that commonly co-occur with them. But if your therapist isn't able to treat your OCD, sometimes people will see two different therapists, with each one focusing on the specific symptoms they specialize in.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington, DC: Author.
Anderluh, M.B., Tchanturia, K., Rabe-Hesketh, S., & Treasure, J., (2003). Childhood obsessive-compulsive personality traits in adult women with eating disorders: Defining a broader eating disorder phenotype. American Journal of Psychiatry, 160(2), 242-247.
Fairburn, C.G. (2008). Cognitive Behavior Therapy and Eating Disorders. New York, NY: Guilford Press.
Kaye, W.H., Bulik, C.M., Thornton, L., Barbarich, N., Masters, K. (2004). Comorbidity of anxiety disorders with anorexia and bulimia. American Journal of Psychiatry, 161(12), 2215-2221.