Is it OCD or an Eating Disorder?

 Jennifer Alosso, PsyD

Since you’re reading this to learn about the differences between obsessive compulsive disorder (OCD) and eating disorders, let’s find out what you know first. Look at the list below. Can you tell who is suffering from an eating disorder and who is suffering from OCD?

  1. Colleen can’t bring herself to eat, even though her weight is dangerously low. She just can’t be sure about what is in the food.
  2. Melissa cuts her chicken, as well as any other meat, into perfect half inch cubes.
  3. Alex enjoyed some toast with peanut butter, but was sure to leave the last bit of it on the plate.
  4. If Patty were only a better person, then she would deserve that ice cream after dinner.
  5. Dan stays away from processed foods, like chips, that are not “pure.” It’s too bad he doesn’t see his friends as much as he used too since they always go out to eat.

How did you do? Were there any that you thought were really obvious? Where there any you couldn’t figure out at all? Whether you are suffering from one of these disorders yourself or watching a loved one struggle, it can be difficult to twist these diagnoses apart at times. Even treatment providers can get confused by an OCD behavior that looks like an eating disorder behavior and vice versa. One person can be diagnosed with both OCD and an eating disorder, but what happens when the behaviors appear to overlap and intermingle with each other? Understanding the origin of the problem is essential for treatment. In order to successfully tackle distressing thoughts, feelings, and behaviors, we need to understand what is driving them. In our investigation into the differences between OCD and eating disorders, we will first learn about their individual characteristics.

A person is diagnosed with OCD when they have recurring unwanted thoughts that create anxiety or discomfort (obsessions), and then engage in repetitive behaviors to try and get rid of that discomfort (compulsions). OCD causes a significant amount of distress and can interfere with work, school, relationships, or any other area in a person’s life. Common obsessions are worries around contamination, perfectionism, danger, and morals. Frequent compulsions include cleaning, checking, repeating, mental reviewing, avoiding, and asking reassuring questions to others.

Eating disorders are comprised of a preoccupation with weight, body image, and food combined with repetitive eating and mealtime behaviors that negatively impact a person’s physical and emotional health. Individuals that have such an intense fear of weight gain that they restrict food intake and are of significantly low weight are diagnosed with anorexia. People with anorexia also may participate in repetitive behaviors around food, such as calorie counting, avoiding meals, purging, or rituals surrounding food preparation and eating. Bulimia involves recurring binge eating (eating large amounts of food at once and not feeling in control of eating) followed by behaviors aimed at preventing weight gain. These behaviors can include vomiting, taking laxatives or diuretics, fasting, or excessive exercise. Persistent worries around body weight and shape are a key feature in both anorexia and bulimia.

You may have noticed some striking similarities between eating disorders and OCD. They both involve obsessive thinking, they both involve recurring ritualistic behaviors, and they both greatly interfere in daily life. Ritualistic eating disorder behaviors can look very similar to OCD and OCD behaviors can center on food and meals. No wonder there can be so much confusion! Since the behaviors in OCD and eating disorders can look very similar, we will have to look beyond the behavior itself and find out why the behavior is happening. Let’s use the examples from above to help us.

Colleen can’t bring herself to eat, even though her weight is dangerously low.
She just can’t be sure about what is in the food.

You may have guessed that Colleen might be suffering from an eating disorder. One of the criteria for anorexia is the restriction of food to the point of very low body weight. If Colleen is restricting food intake because she is worried about gaining weight from eating too many calories, then your guess was correct. However, what if Colleen isn’t worried about her weight at all? It’s possible that Colleen would prefer to be at a normal weight, but is restricting because she worries about contamination in her food that could make her sick. In that case, Colleen’s behavior is due to OCD. The behavior itself does not give us enough information to determine what is causing the behavior.

Let’s look at some more examples of how the same behavior can be a result of eating disorder thoughts (ED) or OCD thoughts…

Melissa cuts her chicken, as well as any other meat, into perfect half inch cubes.

ED thoughts:
“This will help me delay eating and its consequences, like feeling fat.”
“If if control the way I eat my food, then I will have control over my body and my life.”
OCD thoughts:
“Things just don’t feel right unless they are done on an orderly or symmetrical way.”
“Something bad might happen if I do not cut up my food in a perfect manner.”

Alex enjoyed some toast with peanut butter,
but was sure to leave the last bit of it on the plate.

ED thoughts:
“If I gain weight, I might not get attention from others in a way I am most comfortable with.”
“I haven’t completely lost control of my eating if I leave some on the plate.”
OCD thoughts:
“If I eat the last bite, this moment will be gone forever and I will never get it back.”
“God might get mad at me if I act like I expect too much in life.”

Where OCD and eating disorders come together

Sometimes despite our best efforts, it is still difficult to determine if a behavior is due to OCD or an eating disorder. The thoughts behind the behaviors provide evidence for either diagnosis. For example:

If Patty were only a better person, then she would deserve that ice cream after dinner.

Thoughts:
“I cannot eat ice cream now because I need to punish myself for not doing everything I should have done today.”
“The guilt I would feel after eating this ice cream would be too intense for me to handle.”

Dan stays away from processed foods, like chips, that are not “pure.” It’s too bad he
doesn’t see his friends as much as he used too since they always go out to eat.

Thoughts:
“I’m very healthy and will only put organic foods in my body, even if there are no organic foods available for me to eat.”
“The foods at this birthday party aren’t ‘pure’ enough for me to eat, so I will pretend I’m not hungry.”

Characteristics such as perfectionism, excessive guilt, excessive responsibility and unrealistically high standards for oneself are commonly experienced in both OCD and eating disorders. Behaviors related to these characteristics appear to be symptoms of both OCD and eating disorder in some people.

What can be done about all of this?

We know that OCD is best treated with a combination of medication and cognitive behavior therapy, specifically exposure and response prevention (ERP). Eating disorders are usually managed by a multidisciplinary team of providers including a physician, nutritionist, psychiatrist, family therapist, and individual therapist. Unlike OCD, eating disorders are being treated with different types of therapies (cognitive behavior therapy, psychodynamic therapy, etc.) which vary depending on the therapist’s training and experience, and the needs of the client.

Generally when someone is suffering from OCD and an eating disorder, the most problematic of the diagnoses are treated initially. Often the eating disorder takes precedent because of the health risks involved with poor nutrition. OCD might be treated first in situations where there is no immediate health risk and the obsessions and compulsions are more severe or preventing the individual from getting to treatment. This still leaves us to ask: What do we do when OCD and eating disorders team up? Do we treat it like an eating disorder or like OCD?

Researchers have found some success including traditional OCD treatment in the form of ERP to work with both the OCD and eating disorder symptoms1. Though there has not yet been enough research to identify a definite standard treatment for this combination of symptoms, individuals and their therapists may want to consider incorporating ERP strategies into treatment.

If you or someone you care about is suffering from OCD and an eating disorder, please visit the International OCD Foundation’s treatment provider listing to find a qualified professional in your area.


1Simpson, H. B., Wetterneck, C. T., Cahill, S. P., Steinglass, J. E., Franklin, M. E., Leonard, R. C., Weltzin, T. E., & Riemann, B. C. (2013). Treatment of obsessive-compulsive disorder complicated by comorbid eating disorders. Cognitive Behavior Therapy, 42(1) 64-76. DOI:  10.1080/16506073.2012.751124

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