OCD-Anorexia

Obsessive-compulsive disorder (OCD) is the most common anxiety disorder, occurring in 40% of people suffering from anorexia nervosa (Kaye et al., 2004). Both disorders share many phenomenological similarities. The fears and obsessions of people with anorexia nervosa are similar to the obsessions that people with OCD experience. While the anorexic fears gaining weight and becoming obese, the person with OCD fears ingesting food that is contaminated with germs and bacteria and becoming sick. The compulsive behaviors exhibited by anorexics include excessive dieting, over-exercising, repeatedly evaluating themselves in mirrors, and stereotypical weight checking. Food-related rituals, such as cutting food into tiny pieces, are characteristic of both anorexia and OCD. For anorexics, compulsions serve to relief tension and fear of gaining weight, and reinforce ritualistic habits in an attempt to control weight gain.

The personality of individuals with OCD and anorexia is characterized as stereotypically rigid, ritualistic, perfectionistic, and meticulous. According to Murphy et al. (2001), individuals who had a lifetime anxiety disorder diagnosis with an active eating disorder tended to have the highest scores in the categories of anxiety, harm avoidance, perfectionism, and obsessionality. Anorexics also have distorted body images similar to body dysmorphic disorder (BDD) in the obsessive-compulsive spectrum.

The preoccupation with food found in anorexics depicts the intrinsic obsessive nature of the eating disorder. There is a persistent preoccupation with food in a concrete way in the form of involuntary ruminative calorie counting and mental imaging of food, which is experienced as out of the individuals control (Rothenberg, 1990). Along with an obsession with food, there is also a focus on control, which is a core element in OCD.

In addition to these common symptoms, there are biological similarities as well, since serotonin dysfunction has been implicated as one of the possible causes of OCD and anorexia nervosa (Hsu, Kaye, & Weltsin, 1993). These factors have led many investigators to study the relationship between anorexia and OCD. Due to the high comorbidity and phenomenological similarities, many researchers are in favor of broadening the definition of obsessive-compulsive spectrum disorders to include eating disorders such as anorexia nervosa and bulimia.

One distinction between the two disorders is that the characteristics of OCD are ego dystonic while those of anorexia nervosa are more ego syntonic. This difference must be considered in treatment planning. Due to the complication of distorted body images of anorexics, the collaboration between various treatment professionals specializing in OCD and eating disorders is essential for the effective outcome of treatment.

Psychoeducation on appropriate diet, nutrition, exercise, and weight management is foremost important at the beginning and throughout treatment. Cognitive-behavioral therapy (CBT) that addresses abnormal thoughts and behaviors, and that aims at developing coping resources for stress management is the most effective treatment for OCD and eating disorders.

Cognitive restructuring helps to reduce negative self-image, feelings of helplessness, and negative thinking patterns. Psychotropics involving antidepressants and selective serotonin reuptake inhibitors (SSRIs) may also be considered to improve symptoms of anorexia and OCD. Group therapy provides support, and correct inaccurate self-judgments and misperceived information. Furthermore, family therapy provides support and psychoeducation to family members, and addresses underlying family dynamics, which is especially necessary if the patient is a young adolescent living with family members.

Exposure and response prevention (ERP) reduces anxiety of becoming overweight by exposing the patient to images of perceived fat. For instance, patients are instructed to wear tightly fitted clothes, listen to grossly exaggerated loop tapes of images of being overweight, write self-scripts of becoming obese, and experience feelings of fullness after meals. Patients are prevented from excessive exercise and compulsive weight checking. As with BDD, crooked mirrors are used to expose and externalize patients’ distorted internal body images.

This year, two patients with severe OCD and anorexia nervosa have come through the Westwood Institute for Anxiety Disorders, Inc in Los Angeles. One has completed treatment with significant improvements while the other is currently in treatment. Both patients were drastically underweight with life threatening conditions, in which they had to be fed through feeding tubes.

The first patient was a 16-year-old male with magical thinking, fear of gaining weight, fear of making mistakes, and fear of contamination. After breaking his jaw in a skateboard accident, his jaw had to be held up with bandages for a year, which limited his ability to move his mouth and chew. During this healing process, he was only able to feed through tubes. Since he lost weight during the year, he continued to limit his food intake even after his jaw had healed, so that he would not become fat again.

A little over a year later, he experienced a second skateboarding accident, in which he broke his leg. As a result of the two traumas that he endured within the short duration of time, he began to believe that “bad luck” was following him. Within a few months, his magical thinking increased and his obsessive concern with food and weight worsened. He began developing such compulsive behaviors as repeating, correcting, checking, washing, and perfecting. For instance, he would walk around the dinner table and chair again and again until he felt “just right,” or he would have to touch door knobs before engaging in any activity. He also developed food-related rituals, in which he would divide his food perfectly into smaller portions.

During the initial evaluation, his functioning had deteriorated to the point that it was life threatening. He had to be withdrawn from school due to his diminished capacity to concentrate. Rituals became more severe and consumed most of the day. He had lost over 40 lbs within a few months, and his blood pressure continued dropping. He was experiencing black-outs, and was unable to move out of the house. His OCD’s magical thinking was indicative of overvalued ideations, and was tightly intertwined with the anorexia. His Yale-Brown Obsessive-Compulsive Scale (YBOCS) score of 36 and Hamilton Rating Scale for Depression (HAM-D) score of 35 indicated severe OCD and depression.

Due to the severity and comorbidity of his OCD and anorexia, treatment involved 4 weeks of inpatient care at the eating disorder unit at UCLA’s Neuropsychiatric Institute and Hospital. Upon discharge, he participated in the outpatient day treatment program for another 5 weeks. The intensive CBT regimen to target his obsessive-compulsive symptoms also started simultaneously. The treatment utilized progressive exposures to feared stimuli coupled with complete response prevention. Thus, he was discouraged from engaging in all rituals in order to maximize the effectiveness of exposures. In addition to each daily session, he was given two to three hours of daily assignments that closely paralleled the skills acquired from each day’s session.

Over the course of therapy, he struggled with the treatment process. Initially, he had significant difficulties following directions in accordance to this treatment plan, and he put forth only minimal effort in daily assignments. However, toward the end of treatment, his motivation level increased substantially as his obsessional fears declined. At termination of treatment, his YBOCS and HAM-D scores were 7 and 6, respectively.

The second patient is a 14-year-old male with fear of gaining weight and fear of making mistakes. His condition was influenced by his twin brother’s obsession with “healthy food,” and precipitated by a general instruction from his track coach. Within a short period of time, his symptoms deteriorated rapidly. He began developing food rituals, in which he would use his hands to break the food into very small pieces before putting it into this mouth. This ritualistic process increased his meal times considerably, which interfered with other academic and social activities. He also began developing repetitive compulsions, such as flipping light switches, opening/closing doors, pacing up and down the stairs, and touching his face in a particular manner. These rituals had to be performed strictly to avoid “feeling uncomfortable.”

At the initiation of treatment, he was losing weight at the rate of 8 lbs/week due to his food refusal, and was down to a total weight of 87 lbs. He was deficient in electrolytes, his cardiac rate had dropped to the 40’s, and he experienced bladder and bowel retention. He reported that he was having difficulty eating due to the performance of excessive rituals during meal times. His YBOCS score of 39 indicated severe obsessive-compulsive symptoms. Due to his life threatening condition, he was admitted to the eating disorder unit at UCLA’s Neuropsychiatric Institute and Hospital. It has now been 4 weeks since his admission, and he continues to struggle with his condition, in which a feeding tube is necessary to provide him with nutrition.

On an interesting note, his twin brother has also been admitted to the eating disorder program at UCLA. The attending clinicians suspect that he also has some slight obsessive-compulsive symptoms. Specifically, he appears to have obsessive concerns involving “healthy food” that stems from fears of gaining weight and food contamination. His related rituals include reassurance seeking and checking behaviors.

Eda Gorbis, Ph.D., LMFT
Director
Westwood Institute for Anxiety Disorders, Inc.

Jenny C. Yip, Psy.D.
Director of Education
Westwood Institute for Anxiety Disorders, Inc.