Obsessive Compulsive Disorder and Eating Disorders

Eating disorders and obsessive compulsive disorder are often diagnosed at the same time. The different ways these disorders interact can have a vastly different effect on treatment.

One effect of food restriction is the increase in obsessive thinking about food. Our brains are designed to focus more on food when our intake is limited—an adaptive mechanism to survive periods of famine.

The longer the period of restriction continues, the more the OCD behaviors can spread to other parts of life not connected with food.

Many eating disorders involve periods of food restriction. Even if someone binges or overeats at times, any consistent restriction of eating can trigger obsessive thinking about food.

This type of OCD typically responds to normalizing eating. As the body and mind get used to regularly, obsessive thoughts around food, and other things, tend to diminish.

For some people with eating disorders, OCD is an independent disorder that may be exacerbated by, but not a consequence of, the eating disorder. These people have OCD thoughts and behaviors prior to the eating disorder. The obsessions may be about food and also about many other things. Sometimes the OCD itself is the primary issue which focuses solely on the eating disorder at its height and switches to other obsessions through recovery.

For these people, OCD treatment is a necessary part of recovery. If the eating disorder and medical state are severe at first, then the eating disorder needs immediate attention. Once enough stability is achieved, OCD treatment becomes essential.

Medication for OCD largely entails high doses of antidepressants. This treatment can decrease symptoms significantly but is much more effective with concomitant therapy.

Two types of OCD therapy are common. The first is exposure therapy which encourages facing the obsessive fear directly and leads to decreased anxiety around the obsession. This treatment is the gold standard for OCD and is very effective for many obsessions but is harder to do for eating disorder thoughts. Facing the fear of weight gain directly typically is not very effective.

A second type of therapy is called Inference Based Therapy (IBT) which confronts the thought process and lack of logic in OCD. This type of therapy highlights the self-doubt caused by OCD and instead reinforces the idea that there is no real world evidence for the obsession because these thoughts are illogical. This approach can be helpful for OCD related to food thoughts as well.

Distinguishing types of OCD for people with eating disorders increases the likelihood of recovery. Eating disorders are very prevalent and come in all shapes and sizes. Thus, recovery and treatment need to focus on the myriad paths people follow toward health.

Are Ultimatums About Eating Disorder Treatment Ever Ethical

Concurrent with the idea of full recovery is the concept of clinicians giving patients ultimatums about recovery if they are not “fully committed.” At what point is it ethical for a clinician to stop working with a patient because that person is not making progress? Is that decision ever ethical?

When the idea of full recovery is a therapeutic goal, the bar for treatment is set very high with rigid parameters for success. In this paradigm, only people who are committed to recovery, willing to adhere to a meal plan and show up regularly to do the emotional work are acceptable as patients.

However, eating disorders are psychological illnesses with medical consequences which can be severe or even life threatening. Ambivalence about getting well, fear of losing the emotional support provided by the disorder and body image distortion all make recovery very challenging to contemplate, let alone to remain steadfastly committed. Even if the medical consequences frighten clinicians, the professionals need to ensure the safety of the patient and have enough support to feel comfortable doing their jobs.

Any realistic treatment needs to take into account the ups and downs of treatment and the times someone may slip backwards. The vagaries of recovery don’t disqualify people from clinical care, no matter the medical severity. I don’t believe it is ever right to end care without an acknowledgment that the clinician is a part of what isn’t working and with a clear transition to a new treatment team.

But what about the people unable to keep moving forward? What about those in need of emotional support who don’t have the wherewithal to commit to getting well at all? Should they be discarded as if they don’t deserve care? Should they be punished for the severity of their illness?

No matter how one answers these questions, the reality is that many of these people are dropped by providers because they are supposedly not committed enough to treatment. Clinicians should be able to admit the case may be too difficult to manage. The onus is on the clinician to admit their limitations, not blame the patient, and find alternative care. Setting an ultimatum a patient can’t reach only exacerbates the shame already baked into any eating disorder.

Kindness and compassion are necessary components of any recovery. Creating more shame due to supposed clinical ethics is only cruel.

These concepts of “full recovery“ and the “ethical” decision to drop patients both need to reassessed. It’s clear to anyone trying to treat people with eating disorders how difficult that work can be. Clinicians need to own their limitations, set reasonable goals for recovery for each patient and be sure to approach every interaction with kindness and compassion to the best of their ability.

Reckoning with the Idea of “Full Recovery”

There are forces in the eating disorder treatment world promising the idea of “full recovery.” According to the original definition, this term meant getting well and living your life not dominated by the eating disorder. In recent years the term has morphed into an idealized state of life completely free of the eating disorder with everything one could ever want.

Clearly, this concept is a fantasy.

The altered definition of full recovery stemmed from two sources. First, the proliferation of treatment programs staffed by young, inexperienced clinicians promised the unattainable to many people early in treatment as a means to lure them to follow the treatment plan. Second, social media latched into the idea of full recovery as an easy hook for views but not a realistic idea in treatment.

The fundamental purpose of this term is well meaning and intended to give hope and motivation to someone in the weeds of recovery. Even if misguided, “full recovery” helps people struggling in the daily grind of a path to getting well continue to see the purpose and meaning in this process.

Ultimately, anyone familiar with recovery from an eating disorder knows there is a period when the person is in consistent emotional pain as they try to get through the chore of eating each day and facing difficult emotional hurdles. The urge in this time to return to the eating disorder is strong. Continuing recovery at that stage is a leap of faith. One needs to believe there is a different life ahead when the struggle won’t be so great and the growth of new directions in life will begin.

That’s exactly what will happen in recovery. However, the other side is still part of the human condition not utopia. Life can bring amazement and wonder, joy and connection but also hardship and pain, failure and sadness.

Recovery gives someone the chance to live a full life not dominated by the eating disorder. Recovery won’t insulate a person from the vagaries of being human.

“Full recovery” in its current definition may only be an idealized notion—a hope really—for whatever we all wish life might be like. But the term does remind anyone working hard to get well that things can get better and that life not consumed by the eating disorder offers hope for a depth and meaning hard to find in throes of this illness.

The Treatment of People with Normal Weight Anorexia

The Anorexia subtype that is the newest and often most confusing is restrictive Anorexia with relatively normal weights. Some people who restrict their food to a significant degree don’t lose a lot of weight. They have Anorexia. Most people still associate the term Anorexia with very low weights and broadening the diagnosis has been a challenge.

For many years, clinicians and laypeople alike didn’t believe those people who were starving themselves yet remained at relatively normal weights. The general assumption is that these people were exaggerating or even lying about their symptoms, much to the detriment of people with Anorexia seeking help.

Anorexia triggers a metabolic response in people akin to surviving a famine. Our bodies are genetically programmed to adapt to inadequate amounts of food in different ways, all for the sake of survival. Some people remain very active and don’t slow down caloric needs. These people lose a lot of weight quickly. Others slow metabolism over time and can function on small amounts of food and lose weight gradually. Some people slow metabolism right away. Because their caloric needs decrease quickly, this last group functions well enough on small amounts of food at relatively normal weights.

One can see that a varied adaptation to starvation helps the human race survive famine. No one could have predicted the human drive to starve themselves and the consequences of how differently Anorexia can present.

Treating people with normal weight Anorexia is similar to others with low weight. The number one goal is to normalize consistent eating through the day, allow the body to recover normal metabolism and organ function and work on the fears of eating more and gaining weight. Typically, slower metabolism limits the severity of the eating disorder thoughts about restriction and weight gain, for unknown reasons, which allows this subset of Anorexia patients to have a higher chance of full recovery.

The hardest part of recovery for this subtype is that they often don’t believe they have an eating disorder, let alone Anorexia. They too believe that being underweight is a cardinal symptom of this disorder and minimize their food restriction symptoms and illness since their weight is not concerning.

A lot of energy in recovery must focus on the reality of having Anorexia and what that means to the person. Identifying the illness and taking recovery seriously is essential to being able to get well. Education around the varied ways the human body responds to starvation and working on the emotional causes and consequences of long-term restriction are just as important for this subtype. Communicating the diagnosis and treatment with family and friends can help justify the reality of the illness as well.

Over time, a better understanding of Anorexia in the lay population will enable people with normal weight Anorexia accept and seek help for their illness.

The Broader Context of the Diagnosis of Anorexia Nervosa

The diagnosis of Anorexia Nervosa has morphed in recent years into a broader understanding of the illness. However, some of my posts about anorexia don’t always take these changes into account. I’d like to clarify the transformation of the diagnosis.

Anorexia Nervosa originally reflected only the restrictive disease and specific weight criteria without any compensatory behaviors like purging or over-exercise. Over time the diagnosis included subtypes of other behaviors and, only recently, has eliminated the strict weight element of the diagnosis.

The changes are important in order to include all people with the diagnosis and ensure sufficient treatment for everyone. These changes allow that the psychological manifestations of the illness are the same across the board even if behaviors and weight aren’t the same in each case.

The new criteria also merit conversation about varied treatment for the subtypes.

People with anorexia who also are not B at extremely low weights tend to have a more hopeful course. In addition, those people with compensatory behaviors often need treatment that is behaviorally oriented in order to address the compulsive nature of their eating behaviors. Education around these subtypes of anorexia must focus on being malnourished and the effects on organ function and cognition while encompassing body image into the overall recovery.

The original anorexia diagnosis describes a very specific type of eating disorder. These people only restrict, maintain very low weights, tend to feel overweight even when shockingly emaciated and often experience the eating disorder as a loud, demanding voice in their head which they must obey.

This subtype tends to be very difficult to treat and leads to a high likelihood of limited ability to expand their life and early medical consequences. The cause of this subtype appears to be a specific genetic predisposition to prolonged starvation.

When I wrote about anorexia in the recent past, I have called this subtype of anorexia the only type that exists without explicitly naming it as a subtype. The changes in classification necessitate that I differentiate between the types of anorexia.

In the next posts, I will talk more about the varied subtypes and the ways each type is treated similarly and differently.