OCPD, OCD, and Eating Disorders: Is there a correlation?
Written by ‘Ai Pono Hawaii Staff Writer
Many popular media outlets have instilled in us the belief that obsessive compulsive disorder (OCD) and eating disorders (EDs) have a direct relationship. This is because both OCD and EDs are characterized by repeated unhelpful thoughts and damaging behaviors.
However, many new studies investigating the comorbidity (the presence of two or more diseases or conditions at once) of OCD and EDs have found that OCD and eating disorders together are much more complicated than that. The research is still being done on whether there is actually a direct link between the two, or whether comorbidity is just a coincidence.
Obsessive-compulsive personality disorder (OCPD) symptoms and personality traits have also been investigated in relation to EDs, but not as much as OCD. The clinical symptoms of OCPD can be associated with some types of eating disorders. But again, this may just be correlation, correlation meaning that having an ED does not mean you definitely have OCPD, and having OCPD will not directly cause you to develop an ED.
In this article, we will:
Define OCD, OCPD, and what makes them different
Investigate factors that are shared between OCD/OCPD and eating disorders
Talk about what separates the three disorders
Discuss the best ways to treat comorbid disorders
Definition of Obsessive Compulsive Disorder
OCD is defined as the presence of an obsession (an irrational idea about thought or idea that continually repeats) and/or a compulsion (an irrational behavior done repeatedly).
“Obsessions” are way more than everyday worries.
They have specific clinical characteristics:
Irrational thoughts, images, and/or ideas that won’t go away, are unwanted, and cause extreme distress
Thoughts that are distressing enough to cause sufferers to do something about them, such as engaging in compulsive behaviors to make them go away
“Compulsions” are not simply routines.
Instead, they are abnormal behaviors that may include:
Repeating irrational and often ritualistic behaviors like cleaning, hand washing, counting, tapping, or “double checking,” despite having checked something several times already.
Engaging in behaviors out of the fear that something terrible may happen.
Hoarding items out of the fear that something bad may happen if those items are not near them.
Performing behaviors to dispel obsessive, anxiety inducing thoughts, such as a potential illness or the death of a loved one.
Definition of Obsessive Compulsive Personality Disorder
OCPD is characterized by a strict adherence to rituals and routine so as to control their environment, to the point where it becomes detrimental to their wellbeing. OCPD is more than having a strict bedtime routine, or taking the same path to work every day. It is also more than a child’s stubbornness.
There are currently nine distinct personality traits associated with OCPD. You must have four or more of them in your early adulthood in order to be clinically diagnosed with OCPD:
Preoccupation with organization, details, schedules, lists
Striving to do something so perfectly that it interrupts with completing the task at all
Excessive devotion to work and productivity (not due to financial difficulty) that interferes with relationships and personally engaging activities
Excessive conscientiousness and inflexibility regarding moral values
Unwillingness to throw out old items, even if they have no practical or sentimental value
Reluctance to delegate tasks unless they agree to do it exactly as told
A miserly (small, stingy, or unhappy) approach to spending money because they see money as something to be saved for future disasters
Rigidity and stubbornness
OCD and OCPD are two distinct disorders, and while they share some traits, OCD is in its own category in the DSM-V, whereas OCPD is considered a personality disorder. Individuals with OCD can sometimes recognize the ways their disorder interferes with their lives. Those with OCPD, however, are often deluded into thinking that their maladaptive personality traits are normal, good even. This makes sense, as our society values strong work ethics and saving money. But believing that you don’t have a problem makes you reluctant to seek or accept help for it, which is why many with OCPD are reluctant to get help.
OCPD and Eating Disorders: Shared Personality Traits
At the core of OCPD is perfectionism, extreme rigidity, and excessive need to exert control over one’s environment. These characteristics are also used to diagnose some eating disorders. (All eating disorders are not the same, and the same criteria cannot be used for every one.)
Related: Learn more about perfectionism and eating disorders here.
OCD does not, at its core, share these personality traits. When testing for how strongly people with OCD and OCPD had perfectionistic characteristics, people with OCPD had much stronger ties to perfectionism. In this same study, perfectionistic tendencies were also identified in many ED sufferers. The research then suggests that there is a stronger connection between OCPD and EDs in terms of personality (as opposed to OCD and EDs). With both OCPD and EDs, perfectionism and the rigidity required to meet those unrealistic standards cause sufferers to engage in maladaptive behaviors.
Shared Features of OCD and Eating Disorders
Shared Diagnostic Symptoms: Thought Control, Checking, and Hoarding
In this study, 1,619 participants diagnosed with a range of eating disorders were evaluated for different OCD symptoms. As expected, perfectionism was present in many participants. Difficulty controlling thoughts, doubts about everyday things, and repeating behaviors over and over (all OCD symptoms) were also found in ED sufferers. Researchers also found that those who engaged in restrictive behaviors presented with checking compulsions and rigidity around food. Those with binge eating disorder had higher instances of hoarding symptoms than others in the study.
While this study was simply observational, and cannot draw a direct line between the two, it can inform treatment providers about possible comorbid symptoms. This can guide them towards a better way to treat patients with both OCD and an ED.
Related: Body checking is a compulsive eating disordered behavior. Read more about it, and how to stop doing, here.
Inferential Confusion: Mistaking Possibilities and Reality
One of the criteria of OCD in the DSM-IV was that OCD sufferers understood their thoughts and behaviors as irrational, but being powerless to stop them. The DSM-V has updated this criteria to include the following classifications:
Good/fair insight: The individual recognizes that obsessive-compulsive beliefs are definitely, probably, or may be not true.
Poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true.
Absent insight/delusional beliefs: The individual is absolutely convinced that obsessive-compulsive disorder beliefs are true.
Having absent insight and delusional beliefs leads to inferential confusion.
Inferential confusion (IC) is confusing an imagined possibility with a sensory-based possibility, and acting upon the imagined possibility as if it was real. This concept was developed specifically to describe the experience of obsessive thought and subsequent action in OCD sufferers. An example of this concept in practice would be: “If I don’t check to make sure the stove is off three times, then my house will burn down.” The if-then thought process is the inferential aspect of inferential confusion.
And in this case, the OCD thought is so strong, so believable, that the person thinking it becomes confused to the point where they really believe their thought is true. Then they have to check the stove, or (in their minds) their house will burn down. Essentially, IC boils down to confusing possibility with reality. Researchers believed that individuals with EDs may also experience IC, and that it may influence eating disorder behaviors.
In this study, participants with and without EDs were split into two groups. In one group, participants watched videos relating to EDs, but with key parts missing. This led to a distrust in the senses (as they could tell something was missing) and left more to the imagination, and generated a high IC (as they became confused about what they were perceiving, and whether they were correctly perceiving their surroundings.)
The other group watched entire videos, with nothing missing, so they didn’t get confused.
In the end, researchers found that individuals who were made to feel more confused about their perception of reality felt more compelled to engage in ED behaviors. This leads us to believe that individuals who have a more distorted perception of reality are more likely to engage in ED behaviors.
And this makes sense when you think about the everyday experience of an eating disorder sufferer. Someone with an eating disorder may believe so much that they will gain an extreme amount of weight from one meal that it becomes their reality. While this belief is obviously distorted, many eating disorder sufferers wouldn’t even recognize it as so, because it is literally part of their understanding of reality.
Fear of Self: A Concept that Applies to Many Mental Disorders
It’s a very curious thing that OCD usually affects certain parts of an individual’s life, rather than their entire life. For example, someone with an intense fear of germs may not feel the need to constantly make sure their car door is locked.
A prominent theory that explains why those with OCD have their particular form of compulsion is the fear of self theory. Essentially, it says that people have intrusive thoughts that are contrary to how they perceive or want to perceive themselves.
For instance, someone with a compulsive need for cleanliness is actually obsessing about the thought of their surroundings being dirty, which translates to themselves being dirty. That potential self is so terrifying to someone with OCD that they use compulsive behaviors to make sure that intrusive perception never becomes a reality.
The best way to phrase it is: “The more important something is, the worse it seems to have a thought about it.”
The theory was originally used to explain certain aspects of OCD, but now it has been applied to several disorders. While screening for fear of self across several disorders, it was found that disorders involving negative self-perception (seeing oneself in a negative light) have a higher likelihood of constructing a feared possible self. While OCD sufferers do fear a potential version of themselves that would manifest if they did not perform their compulsive behaviors, many of those with EDs have a negative self perception to begin with. And they are very motivated to move away from that negatively viewed potential self.
In this study specifically examining fear of self in EDs, it was found that fear of self exists in the realm of weight and shape perceptions. For example, the fear of a potential overweight self drives someone with an ED to engage in maladaptive behaviors to escape from that fear. But the study also suggests fear of self may be more than skin deep for ED sufferers. The ED sufferer may attribute compulsive behaviors and their bodies as representations of key character traits and moral values. For example, the fear of being “lazy” or “unproductive” may drive someone with an ED to engage in compulsive exercise. They do it to escape the “lazy” self that they have created in their mind.
People with OCD fear who they may be without their behaviors. This is because their behaviors are rooted in some core self-perception. This is the same for many ED sufferers, who believe that their EDs say something about who they are as a person. They believe that, without their behaviors, they will become someone they fear, whether it’s because that feared self is in a larger body, or is perceived in some new way.
Emerging Research: Is there a genetic association between eating disorders and OCD?
A lot of research on the potential relationship between OCPD, OCD and EDs is observational in nature, and may provide differing results. Research investigations into the genetic characteristics of those with mental illnesses is more about the biological reasoning behind them (which is really only one factor that contributes to the development of a mental illness). It is more like looking for a cause, rather than reporting what you find in databases or from interviews. Both provide useful insight, but genetic research can tell us about the exact parts of the body that put someone at risk for OCD, OCPD, and EDs.
Starting in 2018(ish), researchers started putting out their findings. One of the first studies examined the possible shared genetic basis of OCD and anorexia nervosa. They tested whether shared genetic risk for anorexia and OCD was associated with any particular tissue or cell patterns and found that the basal ganglia and medium spiny neurons were most likely to create a shared risk for both disorders. This has been consistent with neurobiological findings for both disorders. The study was not able to paint a definitive genetic picture of OCD and eating disorders. What it did do was get the scientific community more interested in this mode of investigation.
This next study included more genetic data to examine (but still only focused on anorexia patients). While researchers did not find a specific genetic factor that spanned the entire data set of genes, they did find evidence supporting that there is a genetic architecture that is the same in people with anorexia and OCD. And finally, this study examined the genetic association between OCD and all types of eating disorders. Researchers found four common gene types for OCD and EDs. They had a strong functional association with both EDs and OCD.
This is basically saying that there is now evidence of biological associations between OCD and EDs, in addition to behavioral and cognitive ones. Researchers have also suggested investigating genes associated with one disorder to see if it’s a risk factor for the other. So, if you have a specific gene that is related to OCD, you would be able to know if you are at risk for an ED as well.
How to Tell the Difference Between Disorders
The key differences between EDs and obsessive/compulsive disorders are how much importance a person places on weight, shape, food, and exercise. For people with EDs, they are driven to use behaviors out of fear of weight gain, a need to control intake, the use of food to escape emotions, etc.
Essentially, to be diagnosed with an ED, you not only have to have obsessions and compulsive behaviors related to food and exercise — the motivation behind these actions matters. If you, as an individual, engage in food related compulsions, but not because of food fears, rules, body dysmorphia, fear of weight gain, etc., then this is not a compulsion rooted in an ED.
In general, people with OCD are more focused on the interference their compulsions have with their lives. People with EDs are way more focused on weight, shape, and diets. To make sure there is no misdiagnosis, it’s important to analyze the reasoning behind behaviors, rather than just slapping a diagnosis on someone based on a list of symptoms.
Best Methods of Treating Comorbid Disorders
People who present with both an obsessive/compulsive disorder and an ED are very likely to have more severe symptoms and those symptoms may hang around longer than if they were battling only one disorder.
This is how it is with most instances of comorbid disorders. While one disorder is becoming easier to manage, the other one becomes more intense because the individual suffering does not have as many maladaptive coping mechanisms. The best way to recover from comorbid disorders to treat both at the same time. If they’re not treated together, behaviors to manage one disorder can become extreme while the other is being treated.
Simultaneous Treatment Approach: Apply treatment practices for OCPD/OCD and EDs at the same time.
Medical stabilization is usually first on the list when it comes to recovery from an eating disorder. This includes getting on a stable meal plan, taking in adequate nutrition, and reducing maladaptive exercise, binge, and/or purging behaviors. After that, treatment that has been effective for both OCD/OCPD and EDs can be used to treat both at the same time. This includes CBT, a therapy that helps you reframe your thoughts and distortions about reality (which will mitigate IC and help individuals gain insight.)
This also includes exposure therapy. During exposure therapy, you are exposed to something you irrationally fear. You learn to tolerate your discomfort in a safe setting. As you continue to expose yourself to that thing you fear, you will find that the irrational belief you had that made you fear it in the first place is just not true. For example, someone with both OCD and an ED may fear eating food with their hands. On the OCD end, they may fear getting their hands dirty. On the ED side, they may fear the food itself.
During exposure therapy, that individual would have a fear food while in the treatment setting, and continue to do so until they realize that eating with their hands is not terrifying, and that the fear food is really just food. Exposure therapy has proven to be very effective in treating both obsessive/compulsive disorders and EDs.
Transdiagnostic Treatment Approach: Address the common reasons behind the disorders, and treat that.
Many medical researchers and practitioners are starting to view disorders not so much as categories that one is put into, but a series of individual issues which combine to interrupt a person’s life. These issues cause people to engage in maladaptive behaviors. With mental illnesses built on a large-scale spectrum,a transdiagnostic approach to treating people with mental illnesses has been proposed.
This means that medical practitioners wouldn’t see a person who has OCD/OCPD and an ED as someone having two mental disorders. They would see them as an individual, who may have maladaptive levels of rigidity, perfectionism, negative self perception, and fear of who they may be without using maladaptive coping mechanisms to deal with emotional distress.
An example of this in relation to OCD and EDs: Since individuals with OCD and an ED share the difficulties of intrusive thoughts, it would then be in their individualized treatment plan to specifically focus on intrusive thought patterns. And in relation to OCPD and EDs: Individuals who share personality traits that show up in OCPD and EDs would focus on managing their perfectionistic tendencies, rather than categorizing OCPD and ED symptoms separately. Perfectionism contributes to both, so perfectionism is the problem that needs addressed.
Related: Intuitive eating is a way to let go of controlling and perfectionist tendencies in eating disorder recovery. Read more about the intuitive eating process here.
If you or a loved one is suffering from an eating disorder, take the first step today and talk to someone about recovery or simply learn more about the holistic eating disorder recovery programs we offer.