In the world of mental health, several conditions frequently overlap or are found in the same individual. These are called co-occurring or co-morbid conditions.

Among eating disorders, anorexia nervosa (AN) frequently co-occurs with obsessive-compulsive disorder (OCD). The two share a number of similar features, and, in fact, it’s sometimes hard to tell whether someone has one disorder, both, or which one is driving the other.

Still, there are treatment options that have been developed to help the people caught in the crosshairs of these two difficult conditions. These programs can help people change their unhelpful thoughts, face their fears, and learn healthier ways to cope with stress.

How Often Do OCD and Anorexia Nervosa Co-Occur?

Anorexia nervosa and obsessive-compulsive disorder both develop in people as maladaptive coping mechanisms. The heavy reliance on rituals in both conditions serves almost as a balm, offering a sense of control and assurance when someone is experiencing stress or anxiety.

This common link is a powerful one, and likely at the heart of why so many people who experience one of these disorders go on to develop the other.

In fact, research has shown that people with eating disorders are nine times more likely to develop traits of OCD at some time in their life. [1] When it comes to anorexia nervosa specifically, the numbers are even higher.

One study revealed that 19% of patients with AN would go on to develop OCD in their lifetime, while 14% of participants already experienced a co-morbid diagnosis. [2] Another found that anywhere from 35-44% of patients with anorexia nervosa experienced obsessive-compulsive behaviors. [3]

Shared Traits of OCD and Anorexia Nervosa

Primarily, anorexia nervosa and obsessive-compulsive disorder both function as ways to cope with trauma, stress, and anxiety. As such, the conditions share a number of traits, thought patterns, and concerns.

Ritualistic Behavior

When people struggle with OCD, they experience intrusive thoughts, which are only quieted, in their mind, after they perform a certain task, called ritualistic behavior.

For example, someone with the condition may be plagued by the thought, “My whole family will die.” The solution they come up with to alleviate that thought may be to check that the stove is turned off, so the house won’t burn down.

Since the thought is intrusive and pervasive, the person will continue to have it. And this, in turn, drives their continued use of ritualistic behavior.

Anorexia nervosa can develop as a result of this same pattern. Still, whereas with OCD, someone may be concerned about anything from safety to symmetry to the cleanliness of their home, people with anorexia nervosa focus on food and body image.

As such, many ritualistic behaviors of people with AN happen during mealtime. They may:

Cut food into tiny pieces
Eat their food in a certain order
Chew each bite a specific number of times
Keep different types of food from touching

These actions help people to manage their anxiety regarding food. By controlling what and how they eat, they can control their food intake to avoid gaining weight, which is their real fear.

Anxiety

Indeed, fear and anxiety are big drivers of both conditions.

Obsessive-compulsive disorder is technically considered a form of anxiety disorder, with individuals looking to alleviate that stress by controlling their environment through rigid rituals.

People with anorexia nervosa use rules and rituals around food, and sometimes exercise, to feel more secure and safe. Both disorders have intrusive thoughts and compulsive actions at their center.

The link between the disorders is so strong that, when an individual begins to improve from one of these conditions, they may start exhibiting more behaviors of the other, in a subconscious attempt to regain the control they feel they’re losing. Their rigidity can take on another form through the other disorder.

Perfectionism

Researchers say people with both anorexia nervosa and OCD struggle with performance-related concerns. [3] They are driven by a need to be “perfect,” and they feel intense shame and anxiety when they make a mistake.

That performance-related stress only reinforces the need for ritualistic behavior, as the actions can then be used to soothe the shame or fear that arises from any perceived missteps.

Cognitive Inflexibility

Both OCD and anorexia nervosa are upheld by something called cognitive inflexibility.

People who struggle with this trait exhibit a very rigid way of thinking and problem-solving, and they often have trouble adapting to change in their environment. [4]

This kind of mindset is another factor that reinforces the use of ritualistic behavior in both OCD and anorexia nervosa. These actions not only help alleviate stress, but become so ingrained, that the idea of changing them then produces even more anxiety.

Differences Between Anorexia and OCD

While AN and OCD share many common traits, there are a few key differences between the two conditions.

Ego-Syntonic Conditions

Anorexia nervosa is ego-syntonic. This means the individual sees themselves and their condition as one, or experience the condition as part of their identity.

This is one of the aspects that make recovery from anorexia nervosa so difficult. People may become so deeply involved in their disordered thoughts and behaviors that they aren’t able to separate themselves from the condition, or tell who they are without it. [5]

Ego-Dystonic Conditions

On the other hand, obsessive-compulsive disorder represents an ego-dystonic condition. In these cases, individuals have a strong distinction between themselves and the disorder.

People with OCD tend to understand that the invasive and pervasive thoughts they experience are products of their own mind and imagination. In fact, this realization is thought to contribute to their compulsive behaviors. [6]

The stress of experiencing continuous thoughts that one is unable to successfully suppress can cause even more stress, leading someone to lean more heavily on their ritualistic behavior.

Treatment Options for Anorexia and OCD

Anorexia nervosa and obsessive-compulsive disorder share so many of the same drivers and traits, it’s often difficult for doctors to determine which disorder their patients are dealing with, if not both.

Still, some treatments have been developed that can help people struggling with a tricky co-morbid diagnosis.

Exposure & Response Prevention Therapy

Many people with OCD and AN benefit from exposure and response prevention (ERP).

In this program, an individual identifies their fears and, with the help of their therapist, is slowly exposed to situations that arouse these anxieties.

The idea is not so much to remove someone’s distressing thoughts as to normalize the situations that may provoke them. And a therapist will step in to help someone track and understand their thoughts and feelings along the way.

Dialectical Behavior Therapy

Another form of treatment for both OCD and anorexia nervosa is dialectical behavior therapy (DBT).

This form of psychotherapy focuses on helping people make positive changes in their lives, partially by cultivating a greater understanding and acceptance of their difficult thoughts and feelings.

DBT teaches skills that help people expand their rigid thinking to accept the world as it is, rather than relying on ritualistic behavior to cope with things they don’t like about it. It’s helpful for both AN and OCD, as fear, anxiety, and cognitive inflexibility are primary drivers of both.

Group Therapy

Sometimes, people with OCD and anorexia nervosa may benefit from sharing their experiences with others going through these difficult conditions.

In group sessions, they might discuss their fears and rituals. They might also be encouraged to eat their meals together, all while not engaging in their comforting rituals.

Finding Help for Anorexia and OCD

Dealing with anorexia nervosa, OCD, or both can be frightening. You may feel like your life is beyond your control, or that you are beyond help. But it’s important to remember that recovery is always possible.

Therapy or other treatments are available that can help you develop an awareness of why you are struggling, and learn healthy coping mechanisms you can utilize to replace the maladaptive ones.

With these coping mechanisms in place, the world can start feeling like a less scary place, and you can continue along the path to a happier and healthier future.

References

Gramigna, J. (2021, July 20). People With Eating Disorders Have Nine Times Greater Risk of Lifetime OCD. Healio. Accessed August 2022.
Mandelli, L., Draghetti, S., Albert, U., De Ronchi, D., & Atti, A. R. (2020). Rates of comorbid obsessive-compulsive disorder in eating disorders: A meta-analysis of the literature. Journal of affective disorders; 277:927–939.
Levinson, C. A., Zerwas, S. C., Brosof, L. C., Thornton, L. M., et al. (2019). Associations between dimensions of anorexia nervosa and obsessive-compulsive disorder: An examination of personality and psychological factors in patients with anorexia nervosa. European Eating Disorders Review; 27(2):161–172.
D-Arrigo, T. (2020, December). Eating Disorders OCD Common Comorbidities. Psychiatric News. Accessed August 2022.
Gregertsen, E. C., Mandy, W., & Serpell, L. (2017). The Egosyntonic Nature of Anorexia: An Impediment to Recovery in Anorexia Nervosa Treatment. Frontiers in psychology, 8:2273.
Obsessive-Compulsive and Related Disorders: Symptoms. Symptoms. (2022). Stanford University. Accessed December 16, 2022.

The opinions and views of our guest contributors are shared to provide a broad perspective of eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer a discussion of various issues by different concerned individuals.

We at Eating Disorder Hope understand that eating disorders result from a combination of environmental and genetic factors. If you or a loved one are suffering from an eating disorder, please know that there is hope for you, and seek immediate professional help.

Reviewed & Approved on February 22, 2023, by Jacquelyn Ekern MS, LPC
Published February 22, 2023 on EatingDisorderHope.com

The Link Between Anorexia and Obsessive Compulsive Disorder