World Mental Health Day: Shining a Spotlight on the Connection Between Eating Disorders & OCD
This World Mental Health Day, I want to shine a light on two very misunderstood and debilitating mental health conditions: eating disorders and Obsessive Compulsive Disorder (OCD). As a survivor and now therapist who works with clients navigating both conditions, I find it incredibly important to provide understanding, education, and hope that healing is possible.
Eating Disorders
Eating disorders can be deadly. Left untreated, they can lead to death. In fact, someone dies from an eating disorder every 52 minutes in the United States alone. Eating disorders have the second highest rate of death for any mental health condition, with opiate use disorder being the first. This statistic always shocks me and breaks my heart. Eating disorders cause so much suffering that many sufferers go on to die by suicide. As providers, we can prevent more deaths from eating disorders by focusing on educating the public on what they are, how they manifest, and debunking some of the common misconceptions. Hint: eating disorders do not have a look or body size.
Obsessive Compulsive Disorder
Now, why talk about OCD in this context? Well, not only is OCD a very common co-occurring diagnosis with eating disorders (40% overlap rate to be exact), it is also similarly disabling. The World Health Organization lists OCD as one of the top 10 most disabling conditions of all kinds, physical, and mental.
I believe that the misconceptions of OCD add to how disabling it is. The average sufferer goes undiagnosed for up to 17 years, and the longer someone suffers with a mental illness before accessing appropriate treatment, the worse the condition often gets. I can’t help but wonder if awareness, general education, and access to OCD-informed treatment would decrease the disabling impact of OCD.
Beyond Handwashing and Cleaning
Obsessive Compulsive Disorder is often misunderstood as a love for cleaning, organizing, and constant handwashing. This could not be further from the truth. OCD sufferers struggle with a variety of OCD “themes” or subtypes, and contamination is just one theme. People with OCD do not “love” to perform compulsions, they feel driven to do them in fear that something bad might happen if they don’t. They don’t feel like they have control or choice. OCD sufferers often feel deeply ashamed and embarrassed by their compulsions. So why do they do them?
OCD starts with an obsession, also known as an intrusive thought. A fear based “what if” question that triggers intense anxiety, discomfort, and/or disgust. It feels very real; sometimes it is the only thing your brain will focus on, furthering the idea that it’s something very important to pay attention to. Since the intrusive thoughts feel so real and so distressing, people with OCD find ways to quiet these thoughts. They might avoid people or places that trigger the thoughts, or they might develop mental compulsions such as ruminating, reviewing memories over and over, or thinking “good” thoughts in place of the intrusive thoughts. If someone has health-related intrusive thoughts, for example, they might start repeatedly googling symptoms. Others might continually ask their friends and family for reassurance that they aren’t the horrible person OCD is making them out to be. These are all different kinds of compulsions.
Compulsions are behaviors people engage in to try to relieve anxiety from intrusive thoughts. They can be physical or mental, and involve others (reassurance-seeking) or not (avoidance). They provide very short term relief but end up reinforcing the importance of the thoughts to the fear center of the brain (amygdala), which just makes the intrusive thoughts more sticky and present. In other words, the more someone resists intrusive thoughts, the more they persist. It’s a vicious cycle that can make a person doubt everything about themselves and their actions.
Intrusive thoughts are scary and sometimes very taboo, frequently attacking what a person values most. For example, a newly postpartum mother might start to fear that if she doesn’t watch her baby’s breathing pattern every moment the baby is asleep, she might miss something and the baby could die. The mom is then on high alert, repeatedly checking for signs of her baby breathing to make sure this doesn’t happen. Intrusive thoughts can also show up as images in the mind or bodily sensations.
Intrusive thoughts in OCD tend to revolve around several themes, but not every person with OCD will experience every one. These themes include:
Harm: fearing hurting someone else or yourself, or fear that something bad will happen to a loved one
Postpartum: obsessions and compulsions that develop during postpartum, often centered around a parent's new baby
Sexually taboo: fear of being a pedophile or incestual intrusive thoughts
Vehicular harm: hitting someone while driving and not realizing it
Symmetry: obsessive thoughts and compulsions around things being symmetrical
Perfectionism: fear of making a mistake
Relationship: fear of being with the “wrong” partner
Religious/scrupulosity: fear of being immoral or going to “hell”
Social justice-themed: fear of being racist, sexist, transphobic, etc.
Sexual orientation: fear of being the opposite sexual orientation and not knowing it
The possibilities are truly endless but the key is that OCD attaches to a theme that points to something VERY important to the person. Otherwise, the thoughts wouldn’t cause so much distress. Intrusive thoughts happen to many people (with or without OCD), but with OCD, they become incredibly sticky and reinforced by compulsions. For a person without OCD, they simply pass by without much attention paid to it.
To be diagnosed with OCD, you must meet certain requirements: obsessions and compulsions must take up at least an hour of your day, and last for at least two weeks. The distress must also be causing impairment in at least two areas of your life, such as your work and your relationships. An OCD specialist can help you determine if OCD is present. This being said, while understanding the criteria is important, I always tell patients that any amount of suffering with OCD is worthy of care.
Eating Disorders & OCD
Both eating disorders and OCD involve high amounts of anxiety, rigid thought patterns, intrusive thoughts, compulsions, isolation, shame, perfectionism, and harm avoidance. They manifest differently, but share a lot of commonality. Eating disorder intrusive thoughts are centered around food and body. Compulsions can be seen as any behavior done to relieve body shape/size and eating related distress. (Please note that this is different from accommodations and food preferences in ARFID and sensory needs in Autism). Eating disorder compulsions can include but are not limited to: restricting, bingeing, self-induced vomiting, over exercising, rituals with food or cutlery, counting calories, tracking weight, weighing food, body checking, and so much more.
Both eating disorders and OCD also tend to present with rigid or unhelpful thinking patterns, also known as cognitive distortions. These thought patterns can include black and white thinking, emotional reasoning, intolerance of uncertainty, over importance of thoughts, thought action fusion, and hyper-responsibility. Part of why intrusive thoughts feel so real and important is because of these thinking patterns. So much relief can be found in developing a more flexible and compassionate relationship to our thoughts.
Another similarity between eating disorders and OCD is the presence of state traits or temperament styles, such as: perfectionism, highly sensitive, highly anxious, obsessive guilt, and harm avoidance. Not all eating disorder and OCD sufferers share these traits, but many of my patients do. While these temperaments can cause suffering, they are not “bad” — rather, they often point to a deeply sensitive and empathetic person. When these traits are channeled in a healthy way, creativity, connection, a commitment to justice, and radical compassion emerge.
Breaking the Obsessive Compulsive Cycle
Another commonality between eating disorders and OCD is the presence of an obsessive compulsive cycle. It goes like this: there is an intrusive thought, anxiety and discomfort about the intrusive thought, a compulsion aimed at reducing distress, temporary relief, and then the cycle repeats. See the below image for a helpful visual!
The reason the cycle repeats is because the compulsion reinforces the fear; the more you pay attention to the intrusive thought and engage in compulsions, the more the fear will stick in your brain.
Gradual exposure work, guided by a compassionate specialist who moves at your pace, is vital in eating disorder and OCD recovery. Since we can’t control what thoughts pop into our brain, we focus on the behavior (the compulsion). When we learn to face our fears without using compulsions, we can reduce distress and step out of this cycle. In eating disorder treatment, this could look like eating fear foods without binging after. In OCD treatment, it might look like holding your baby even though you have scary thoughts about hurting them. Intrusive thoughts are not facts, and we can show our brain this through our actions and commitment to our values.
Strategies for Coping
Over my 10 years of practice as a therapist, I’ve found that the most effective strategies are rooted in mindfulness skills, Acceptance and Commitment Therapy (ACT), and Exposure Response Prevention therapy (ERP). When dealing with OCD, we don’t want to challenge the thought. This can become compulsive and tends to only make the intrusive thought stronger. Instead, we want to practice noticing the thought without doing any sort of compulsion, including ruminating. I tell my clients to treat it like a bee on your shoulder (thank you to OCD therapist Alegra Kastens for the metaphor). Simply notice the discomfort and let it be there until it decides to pass. If you fight or run from it, you will only aggravate it, and the metaphorical bee might even sting you. When you accept its presence without judgement and continue whatever it was that you were doing before you noticed the bee, it eventually passes. This is an example of thought defusion and building psychological flexibility, from Acceptance and Commitment Therapy.
Developing self compassion is also key to coping. Dealing with OCD or an eating disorder is HARD. Working on changing the brain’s response to these distressing thoughts is VERY HARD. We can’t shame our way into change, so learning to treat yourself and your brain with compassion is foundational to healing.
Another important thing to note is that learning to tolerate the distress these thoughts bring, without acting on them or using compulsions, is ultimately the key to lasting freedom. This is part of ERP, the current gold standard approach for treating OCD. By facing our fears without using compulsions, over time our brain learns a very important lesson: I can have intrusive thoughts, not act on compulsion urges, and the anxiety will naturally go away. Through this process, the intrusive thought becomes less anxiety provoking and loses its power.
Note: ERP is not for everyone and other evidence based treatment models exist. Inference Based CBT (I-CBT), for example, does not require exposure, which can feel more accessible to some neurodivergent folks.
Seeking Proper Treatment
My final recommendation is to seek proper treatment. If you suspect you have both an eating disorder and OCD, please find a provider who specializes in both. Sometimes traditional eating disorder treatment can make OCD worse, and vice versa, because the techniques used to cope will look different. I recommend looking up qualified OCD providers through the International OCD Foundation, and narrowing down to providers who also identify eating disorders as a specialty. If you are located in CA, WA, UT or FL, my team at Eating Disorder and OCD Therapy would also be happy to help. We all have professional and lived experience with both eating disorders and OCD, and feel a deep passion for helping others find peace from the pain these struggles bring. All in all, please know that you are worthy of care and recovery; I have so much hope for you!
