In a recent article in the OCD Newsletter, entitled “OCD and Anorexia,” psychologists Eda Gorbis, Ph.D. and Jenny Yip, Psy.D. highlight the striking similarities between these disorders. Obsessive-compulsive disorder (OCD), an anxiety disorder characterized by obsessive thought patterns and/or behavioral (or mental) compulsions, seems to be linked to the restriction and compulsions around food, typical of eating disorders. In fact, it’s estimated that almost half of those diagnosed with anorexia also meet criteria for OCD. Looking at an eating disorder, it’s hard not to see the components of OCD: ruminations about calories consumed or weight gained, compulsive weighing/mirror-checking/exercise, purging as compulsive compensation for a binge.
Both OCD and EDs have been linked with imbalances in the neurotransmitter, serotonin. As such, selective serotonin reuptake inhibitors (SSRIs) are the psychotropic line of defense for both. And finally, similar therapeutic interventions are effective for both. Cognitive-behavioral therapy, which addresses dysfunctional thought and behavioral patterns works quite well in both group and individual settings with each patient population. Exposure and response prevention, a specific behavioral intervention that involves exposure to anxiety-provoking stimuli with the simultaneous prevention of a target behavioral response (e.g., OCD patients might be instructed to “sit with” feelings of contamination while avoiding hand-washing, ED patients might be instructed to “sit with” feelings of fullness after a meal without purging or running to the scale or mirror for self-evaluation) has demonstrated significant efficacy rates as well.
According to Gorbis and Yip, some researchers are considering the idea of subsuming eating disorders under the OCD diagnosis. Taking a look at the criteria for OCD from the current Diagnostic and Statistical Manual (DSM-IV; APA, 1994) below, it seems clear that if we substitute calorie counting, fears of gaining weight, mirror-checking/weighing, and/or bingeing/purging with some of the behaviors provided, we might just have a good fit. One notable difference is that described under criterion B, which suggests that in OCD, the obsessions or compulsions are recognized to be unreasonable. In some eating disorder constellations, particularly those that are more restrictive in nature, it seems that this criterion may not be met.
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A. The Person Exhibits Either Obsessions or Compulsions
Obsessions are indicated by the following:
1) The person has recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress.
2) The thoughts, impulses, or images are not simply excessive worries about real-life problems.
3) The person attempts to ignore or suppress such thoughts, impulses, or images or to neutralize them with some other thought or action.
4) The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion).
Compulsions are indicated by the following:
1) The person has repetitive behaviors (eg, hand washing, ordering, checking) or mental acts (eg, praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
2) The behaviors or mental acts are aimed at preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.
B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. (Note: this does not apply to children.)
C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person's normal routine, occupational/academic functioning, or usual social activities or relationships.
D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with drugs in the presence of a substance abuse disorder).
E. The disturbance is not due to the direct physiologic effects of a substance (e.g., drug abuse, a medication) or a general medical condition.
12 comments:
I'm not surprised to hear this correlation at all. For years, I've equated BED as a form of OCD for me. At times, it's actually debilitating for me -- for hours, days and even weeks on end. I literally can’t shut the “food talk” off in my head. Whether it’s planning another binge, planning a restrictive course to counteract the effects, thinking about how much I shouldn’t be eating something or beating myself up for what I’ve already done. This self-talk in my head is so loud sometimes I literally cannot concentrate on anything else. Early on in my treatment I was prescribed Prozac to help calm this down and I have to admit, it worked for me. I didn’t however, like some of the side effects from the drug and as soon as I was able to go off of it (I was only on it for a couple of months) I went off, feeling more in control and quieted. I will definitely be interested to see what further research reveals around this correlation.
Interesting post, Dr. Stacey. I can definitely see the correlation between the two.
The constant weighing, etc, it all makes sense. I definitely don't like the idea of "sitting with" the feelings of fullness. There's nothing I'd rather do less. Makes me cringe to even think about. It's scary!
I'll probably think of more to say about this later but that's it for now.
It's interesting you draw the distinction at whether the person recognizes their obsessions/compulsions as "reasonable." People with OCD are certainly caused a significant amount of distress by their disorder - people with obsessive compulsive personality disorder don't. I don't know if i'd link ED to OCPD though...
Also, I think it's much more common for bulimics and people with bed to recognize their behavior as unreasonable...I've frequently wondered whether restrictive-type EDs should be in a different category altogether from bingeing and purging-type...
Just thinking out loud.
#E, concerning lack of physiological source doesn't quite fit with eating disorders, either. As the research of Dr. Garner and even Key's original starvation studies show, many of the behaviors exhibited by those suffering from eating disorders are normal physiological reactions to dieting- induced starvation.
Sandy
For me, after dieting and non-dieting-- for over a year and realizing sugar is not agreeable with my system--, I'm finally cutting sugar and caffeine out slowly and upping my protein and eating a complex carb at breakfast for now and moving slowly. I find that as long as I do this, all my binge urges *magically* disappear where nothing else has worked. I know it's neurotransmitter related... serotonin, beta-endorphin wise. I feel soooo much better overall too and my muscles and body feel like my own again. It's hard to explain, but I finally realize I was sugar sensitive, and this is the only thing that is bringing me peace and sanity from obsession with eating, not eating, dieting, bingeing, wanting sugar, craving, etc. I thought I needed therapy, etc. and that never helped; SAM-e for depression helped very marginally because it only deals with serotonin. This is the only thing that has worked... so glad I've figured it out for myself...
Enjoying your blog...
Lisa
jen--me, too. Thanks for commenting on your experience.
ptc--the "sitting with" part is pretty difficult at first, though it can be learned with practice (and motivation).
elisse--people w/OCD realize their obsessions are unreasonable--though many with anorexia deny the problematic reasoning associated with their behavior. Not sure abt the correlation between OCPD (a personality disorder, distinct from OCD, which is an anxiety disorder) and ED. I agree on the anorexia/bulimia distinction--it's harder to accept a behavior that's "uglier" according to our cultural definition.
sandy--interesting and certainly true for those w/a history of restriction.
lg--thanks. And thanks for sharing your experience--glad you're feeling better.
I'd rather stand. ;)
Hey Dr. Stacey,
Would you mind furthing explaining this, please?
"people w/OCD realize their obsessions are unreasonable--though many with anorexia deny the problematic reasoning associated with their behavior."
I get it, I think. Are you trying to say that people with anorexia make excuses for their behavior so they believe what they are doing is normal? Or that anorexics are denying the underlying issues behind their eds?
I feel stupid because I think I get what you're saying but I'm not sure I do. I love when I feel like I dumbass.
As for "sitting with" the feelings, would you suggest that someone dive head first into their fear of food and experiment with those feelings or just take it slowly?
For example, if I were to sit down and eat hmm, let's say a plate of french toast, what positives would come out of me sitting there feeling absolutely disgusting and miserable and freaking out about it? I'm curious about that.
Thanks!
ptc--not stupid at all. . . I meant the first of your statements--that those struggling w/anorexia often deny the severity of their condition, or have a way of reasoning that it's not that bad.
As for your 2nd question, I'd say baby steps might be more appropriate (and reasonable). The goal is to experience the anxiety, have it dissipate (as it's certain to do w/time), and realize that it's manageable. Eventually, the feelings of misery and disgust would pass, and you'd have the new experience of mastery over the food-phobia and the accompanying anxiety.
Thanks, doc!
To anyone,
Any recommendations for treatment with Dr. Eda Gorbis?
i think i have an eating disorder ive been reading all of the thing you have been typing and if you have you facts right i can relate to almost every point . im scared
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