The Importance of Addressing OCD and Other Anxiety Disorders Symptoms in the Treatment of Eating Disorders
By Theodore E. Weltzin, MD
Nicolette Weisensel, MD
Tracey Cornella-Carlson, MD
Bradley C. Riemann, PhD
Pamela Bean, PhD.
Rogers Memorial Hospital - Eating Disorder Center
Eating disorder symptoms can be more severe for those also struggling with a co-occurring anxiety disorder like obsessive-compulsive disorder. Rogers Memorial Hospital has recently developed a residential program that specifically uses evidence-based treatment for both eating disorders and anxiety disorders. While effectively addressing anxiety disorder symptoms in eating disorder patients can be challenging, preliminary results show a significant reduction in both anxiety and eating disorders symptoms. In the spring of 2008, Rogers Memorial Hospital will open a new residential treatment center that features a specialized program for those with co-occurring anxiety and eating disorders.
A substantial number of those diagnosed with anorexia or bulimia present with at least two co-morbid psychiatric illnesses at admission to treatment (Bean et al., 2005; Blinder, Cumella & Sanathara, 2006). The presence of anxiety disorders, including obsessive-compulsive disorder (OCD) , have been consistently found in patients who were already being treated for eating disorders in an outpatient or an inpatient setting (e.g., Bean, 2006; Kaye, Bulik, Thorton, Barbarich, & Masters, 2004; Rabe-Jablonska, 2003). Findings indicate that OCD is present in a low of 10% (Lucka, 2006; Rabe-Jablonska, 1996), a median of 20-37%, (e.g., Bean, 2006; Rubenstein, Pigott, L'Heureux, Hill & Murphy, 1992; Thiel, Broocks, Ohlmeier, Jacoby & Schussler, 1995) and a high of 56% (Blinder, Cumella & Sanathara, 2006) of all eating disorder patients. Both conditions have a peak age of onset during adolescent years and interestingly, OCD prevalence is increased in both anorexic and bulimic eating disorder subgroups. OCD was found to be two times more common in patients with a diagnosis of anorexia (Blinder, Cumella & Sanathara, 2006; Lucka, 2006) compared to bulimia.
Connections and complications
Anxiety and eating disorders could represent a different presentation or expression of a common neuro-biological abnormality or risk factor. The expression of this biological vulnerability could relate to the magnitude of the vulnerability and/or unique environmental experiences, as well as other factors. Additionally, data suggests that patients with co-occurring eating and anxiety disorders may have a more severe and/or more treatment resistant eating disorder. Thus, the relationship between eating disorder and OCD might be of immense clinical relevance with regard to prognosis and treatment.
Patients with both eating and anxiety disorders may have more severe eating disorder symptoms. Studies have shown that subjects with anxiety and eating disorder co-morbidity have a longer history of eating disorder and that subjects who suffer from OCD are likely to have developed an eating disorder at an earlier age. (Milos et al. 2002) Other treatment teams have reported that no matter whether the eating disorder or OCD came first, OCD symptoms have a significant effect on treating the eating disorder. (Fisher et al., 2002). These findings were also found in a more recent study conducted at Rogers Memorial (Weltzin et al, Dec 2007, Eating Weight Disorders Journal). Eating disorder patients with co-morbid OCD exhibited a higher score in the Eating Disorder Inventory (EDI) than eating disorder patients without a co-morbid OCD. They found that eating disordered patients with and without a lifetime diagnosis of OCD scored highest on the subscales of drive for thinness, body dissatisfaction, and ineffectiveness. (Lennkh et al. 1998) Another study noted that similar subscales of the EDI - drive for thinness, body dissatisfaction, and perfectionism differed significantly between an eating disorder group and a control psychiatric group (Cassady et. al., 1999). The eating disorder group scored higher in all three scales. Furthermore, between three percent and 13% of adults and children diagnosed with anorexia and OCD also met the DSM-IV-TR criteria for depression, with females sustaining a higher rate of incidence than males (Rabe-Jablonska, 1996; Lucka, 2006; Noshirvani et al.1991).
Aversion to change
Increased anxiety with change may reduce the efficacy of eating disorders treatment. In patients with co-morbid anorexia nervosa and OCD, introducing new foods and reinforcing typical eating patterns were much more difficult compared to patients with anorexia nervosa alone. Generalized anxiety disorder has been identified as being most strongly associated with anorexia nervosa in patients requiring hospitalization for their eating disorders (Godart et al., 2005; Lucka, 2006). While there are few studies available focusing on the impact of known treatment modalities for anxiety disorders on the course and treatment of eating disorders, effectively addressing co-morbid OCD and other anxiety symptoms should improve treatment efficacy and outcome for eating disorder patients. A follow-up study found that patients whose eating disorders were most improved at the 30-month follow-up also showed the highest reduction of obsessions and compulsions (Thiel et al., 1998).
Treatment can be challenging
Effectively addressing anxiety disorder symptoms in eating disorder patients can be challenging. As compared to depression, the treatment of anxiety disorders, (particularly in children, adolescents and young adults) relies less on pharmacotherapy and more on psychotherapy. Antidepressant medications, often used for the treatment of anxiety disorders, are associated with an increase risk of treatment emergent suicidal symptoms in this age group. Studies suggest that behavior therapy including exposure with ritual prevention is as effective for OCD (if not more effective) as compared to pharmacotherapy. Skilled behavior therapists are not often available and the time required to develop the skills to be an effective behavior therapist are often prohibitive for most clinicians. These factors, as well as the combination of eating and anxiety disorders, represent a unique challenge to the patient families and clinicians.
At Rogers Memorial Hospital we have developed a specific residential program that uses evidence-based treatment for both eating disorders and anxiety disorders. Preliminary results have been quite encouraging as we have found a significant reduction in both anxiety and eating disorders symptoms (Riemann et al, 2006). Furthermore, a recent study of length of stay seems to suggest that this combined modality may actually reduce the time needed for treatment. Results are preliminary but encouraging and support further development of specific eating disorder treatments that address co-morbid anxiety disorders.
Rogers Memorial Hospital is a nonprofit behavioral healthcare provider for children, adolescents, adults and older adults. The hospital is nationally recognized for its residential treatment centers including the Eating Disorder Center, Obsessive-Compulsive Disorder Center and the Child and Adolescent Center. Rogers Memorial also provides residential treatment services for chemical dependency and co-occurring OCD and other anxiety disorders. Inpatient and partial hospitalization services are also available. Rogers Memorial is licensed as a psychiatric hospital by the State of Wisconsin and accredited by the Joint Commission. It offers treatment programs at four Wisconsin locations: Oconomowoc, Milwaukee, Kenosha and Brown Deer. To learn more, please call 800.767.4411 or visit us online at www.rogershospital.org.