How OCD Can Fuel Disordered Eating

This is a guest post by Jackie Shapin, a Licensed Marriage and Family Therapist who specializes in anxiety, OCD, and eating disorders.

There is a significant crossover between obsessive-compulsive disorder (OCD) and eating disorders. Because OCD symptoms commonly fit into the category of disordered eating and even diagnosable eating disorders, teasing the two apart can be a challenge. Unfortunately, I’ve heard too many stories about clients who receive eating disorder treatment when in reality, the problem is OCD.

Despite this overlap, there are key differences—and the biggest one comes down to the “why?” Understanding what drives compulsions around food and body is an important part of getting the right support. Let’s explore how OCD can influence that relationship.

Disordered eating vs. eating disorder

Both disordered eating and eating disorders include problematic eating patterns. While they share these similarities, they are not the same.

Disordered eating may involve unhelpful eating patterns and behaviors, including dieting, skipping meals, eating foods in a certain order, taking micro-sized bites, eating very slow or fast, avoiding certain foods or food groups, binge eating, and purging through use of laxatives, exercise, or self-induced vomiting (among others). It can also include all-or-nothing, extreme, rigid, or critical attitudes toward one’s own food choices and body.

Disordered eating doesn’t meet the frequency, duration, and/or other criteria of diagnosable eating disorders such as Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, Avoidant/Restrictive Food Intake Disorder (ARFID), and Other Specified Feeding or Eating Disorder (OSFED). But both can lead to negative medical, physical, and psychological consequences.

How does disordered eating show up in OCD?

As a refresher, obsessions are the thoughts, feelings, ideas, or beliefs that pop into our mind, without our control, that increase our distress, anxiety or disgust. Compulsions are then used as an attempt to cope with, get rid of, or lessen distress, anxiety, and/or disgust. Within OCD, compulsions can be grouped into 5 different categories: 

1. Physical or behavioral
2. Avoidance
3. Reassurance-seeking
4. Other mental compulsions
5. Self-punishment 

Obsessions and compulsions can exist in both OCD and eating disorders, but they are key criteria to OCD and are not always labeled this way with eating disorders.

What’s important to realize is that even if a compulsion is solely coming from OCD, it can impact the way we treat our bodies and can turn into disordered eating, creating an unhealthy relationship with food and exercise. The following are examples where eating can become compulsive in someone with OCD, or in some cases, ARFID:

Physical or behavioral:

• Restricting certain food groups because of the fear that certain foods are contaminated and may make the person sick
• Only eating certain foods believed to have high nutritional value because of the fear that if a person doesn’t eat “just right,” something bad will happen
• Counting, touching, or eating food in a certain way that feels “just right” or that the person believes is “perfect” or “good enough”
• Eating micro-bites, or only eating certain foods, out of fear of choking or vomiting
• Restricting foods for fear of inducing nausea or vomiting
• Excessive exercise or exercising in a way that gets in the way of quality of life because of fears around health, or “just-right” irrational beliefs around moving the body (magical thinking—the belief that thinking something will make it occur—may apply to this type of compulsion)

Avoidance:

• Avoiding entire food groups, brands of food, or foods with a certain appearance due to fear or disgust related to contamination, just-rightness, being “good,” nausea, vomiting, choking, or belief of medical consequences
• Avoiding certain (or all) exercises due to fears of getting hurt, getting sick, or dying

Reassurance-seeking:

• Asking oneself or others if a food has been washed, if a food is fresh or organic, how many calories a food may contain, where a food is sourced, etc. to lessen distress around contamination, getting sick, disgust, just-rightness, magical thinking, or vomiting

Other mental compulsions:

• Rumination: Reviewing past meals or snacks, counting calories or food groups as a way to “figure out” or remember if anything would cause nausea, vomiting, sickness or something “bad”
• Counting: Specifically counting calories to review for perfectionism or just-rightness, or due to magical thinking about a specific number having meaning

Self-punishment:

• Eating excessive amounts of food or excessively exercising, or denying food as a way to punish oneself if a person thinks they are bad, have done wrong, are not deserving, or believe it will decrease their distress or fears

When you look at these compulsions under the framework of OCD, it’s easy to see how someone might observe them and be drawn to an eating disorder diagnosis. This is why differential diagnosis, the process of looking at all of the different possibilities of a diagnosis and ruling them out with further assessments to determine the correct diagnosis, is important to ensure patients receive the right treatment.

It’s also important to rule out that none of the compulsions are the result of medical necessity, allergies, or any other medical diagnosis. The symptoms causing the most functional impairment in an individual’s life should be treated first.

Medical complications

There are numerous medical complications that can occur when food and body become a part of the OCD cycle. These include osteopenia and osteoporosis (loss of bone mineral density or change in bone mass, structure, or strength), decreased brain function, fatigue, unhealthy vitals, blood pressure issues, amenorrhea (loss of menstrual cycle), and many more.

If your OCD has led to disordered eating, I highly recommend seeing a doctor to rule out medical complications and ensure your safety. When treating OCD, if there are compulsions contributing to health problems, focus on these rituals first, if possible, or create a plan that directly includes working on reducing these behaviors.

What’s next?

When starting treatment for OCD, it is important to prioritize psycho-education—especially when food and body are involved in the OCD cycle, or where rules and beliefs about body and food are part of the cycle. Seeing a registered dietician can help dispel myths on health and wellness and provide helpful, correct information that social media, our friends, and the internet can get wrong. It’s important to pick a trusted, reputable source, and ideally just one. This will lower the chances of education becoming compulsive or reassurance-seeking. 

After proper education, discovering core beliefs and motivation to change are key components of recovery. Exposure and Response Prevention (ERP) therapy follows as an evidence-based treatment for breaking the OCD cycle. Learn more about this treatment here. Inference-based cognitive behavioral therapy (I-CBT) is another great treatment method that can be used to treat OCD.