Eating disorders and obsessive compulsive disorders

Christopher Fairburn defines an eating disorder as a persistent disturbance of eating or eating-related behavior that results in an altered consumption or absorption of food and that significantly impairs physical health and/or psychosocial functioning. According to the Special Issue on Eating Disorders in the American Psychologist in April, 2007, eating disorders rank among the 10 leading causes of disability among young women and anorexia nervosa has the highest mortality rate of all mental disorders. Recovery from an eating disorder has been an enormous challenge for a clinician to treat as well as for patients and their families to overcome.

Eating disorders might be looked at as a variation of obsessive-compulsive disorders (OCD) in terms of how symptoms present themselves. Compulsive eating, continual self-starvation, the ritual of the binge-purge cycle, and obsessive exercise habits all become rigid patterns of behavior that are resistant to change and potentially life-threatening. The intense fear of becoming obese, the disturbance of body image, the steadfast refusal to maintain a normal body weight by decreasing fat and carbohydrate intake that characterize anorexia nervosa are not unlike the recurrent obsessions and compulsions that provoke distress and often interfere with everyday functioning so characteristic of OCD. Likewise, in bulimia nervosa, the repetitious cycle of compulsive binge-eating and purging, whether by self-induced vomiting, laxative abuse, or excessive and obligatory exercise, are fairly suggestive of the repetitive rituals or mental acts exhibited by OCD patients... For example, the obsessive counting of calories or the compulsive acts of purging are ritualized behaviors performed in response to an obsessive fear (becoming fat) and are designed to suppress or neutralize discomfort (feeling fat) or to prevent a dreaded event (weight gain). As in OCD, the obsessive compulsive rituals of individuals with eating disorders consume their lives, with every waking moment being food centered. However, the consequences of rigid starvation and compulsive exercising resulting in rapid weight loss, bring about more describable and perhaps more self-reinforcing results to an individual with an eating disorder, unlike the hand washing and checking rituals of classic OCD patients where the elimination of germs or the safety from dreaded events is less visible and apparent.

In 1984, Albert Rothenberg , then Director of Research at the Austen Riggs Center, in a presentation, Eating Disorders as a Modern Obsessive-Compulsive Syndrome, identified three main common factors between eating disorders and OCD: the obsessional concern with food with the persistent preoccupation far excessive to the goal; the focus on control of weight, appetite, thoughts, environment, and bodily functions; and defensive patterns, such as doing and undoing, reaction formation, intellectualization along with obsessive-compulsive behavior patterns such as perfectionism, orderliness, cleanliness, meticulous attention to detail, negativism, rebelliousness, and intense dedication to physical activity.

In 1991, in his publication, Obsessive Compulsive Disorders and eating Disorders, Steven Levenkron from his own clinical work with anorexic and bulimic patients, speaks of the obsessional personality characteristics in these individuals, namely their inflexibility, feelings of emptiness, and their defiance. Levenkron also outlined four stages in the evolution of an eating disorder: first, the stage of achievement, or competition with other women for thinness; second, the stage of the security system, whereby one is soothed and assured by rigid behavior patterns to combat anxiety; third, the stage of secondary gain, whereby one sees others responding with increased attention and nurturance; and fourth, the stage of pseudofunctional identity, whereby one perceives one’s symptoms as comprising identity and assertiveness.

In treating the obsessive-compulsive symptoms of an eating disorder, a sound treatment approach is important both in terms of comprehensive assessment, normalization of weight and eating, and family intervention. The treatment approach must also incorporate collaborative work with other medical and health professionals to safely monitor physical functioning. Working with the patient’s family also can be an important focus both to enlist support and remove obstacles to treatment.

The assessment of a patient with an eating disorder should be comprehensive with a goal towards identifying the appropriate level of treatment. Miller and Rollnick in 2002 in Motivational Interviewing outline five levels of treatment: first, the stage of pre-contemplation whereby the patient is in denial or unwilling to accept the problem; second, the stage of contemplation, in which the patient knows there is a problem but is afraid or unprepared for change; third, the stage of preparation, whereby the patient does not know how to change or what to do; fourth, the stage of action, in which change can be implemented and there is readiness and learning; and fifth, the stage of maintenance, in which there is action with increased ease toward change. When treating an eating disorder, each symptom, whether it may be restricting food intake, binge behavior, purging, the refusal to maintain normal body weight, or body image distortion, must be assessed separately according to this approach. For example, an individual may be ready to take action to stop restricting calories but would still be afraid or not know how to stop the purging behavior.

When treating eating disorders, achieving recovery without normalization of weight and eating is a contradictory goal. Though not in and of itself sufficient, weight restoration is a necessary condition for meaningful change. As part of the clinical treatment, weight monitoring should be done on a regular basis preferably by a physician, nurse, or a nutritionist. In most cases, the patient should not do their own weighing more than once weekly, in order to decrease obsessional thinking about the number on the scale. The nutritionist can be an important part of the treatment team in terms of achieving the goals of normal eating, normal attitudes towards food, and normal responses to hunger and satiety cues. While the patient is being monitored physically by a physician and taught to eat normally by a nutritionist, the treating psychologist can provide a cognitive-behavioral approach to the normalization of weight and eating. Typical cognitive-behavioral interventions in treating anorexia nervosa would include the challenging of distorted beliefs about gaining weight such as becoming obese, the fear of gaining weight in one place such as the stomach or thighs or having to know one’s exact weight to get through the day. Another behavioral intervention for psychological treatment is exposure plus response prevention (ERP), which can be very useful in eliminating the binge-purge cycle of bulimia nervosa. ERP as an intervention is based on an anxiety reduction model of the binge-purge cycle with purging reducing the anxiety of the binge or even moderate food intake. This model is analogous to the anxiety –reducing compulsive behaviors is OCD such as hand washing. However, the difference lies in the fact that repeated hand washing never completely resolves the dread of contamination whereas bulimia patients become more and more secure in the magical protection of vomiting. In treating the bulimic binge-purge cycle, the basic ingredients are: exposure to the feared stimulus, such as eating particular foods or amounts of foods and prevention of the habitual compulsive escape response such as vomiting. Prevention can take place by either response delay or ritual restriction which is the gradual limiting of the time of each ritual or selective ritual prevention, the setting of a hierarchy from easy to hardest. Also the use of a food diary can be very useful in the behavioral assessment of EPR target symptoms such as food avoidance, vomiting after eating, or irrational beliefs. The food diary should record all food and liquid intake, time of day eaten, amount of food eaten, amount of anxiety for an eating episode (0-10), whether an eating episode is considered a binge, whether or not they vomit or take laxatives. The reasons for the decision to purge during the day and the feelings associated with it should be explored by the psychologist. The distorted beliefs about body shape, food and eating behavior are cognitive mediators that serve to sustain the vomiting which is governed by a set of rules about safe or forbidden foods. The diary also can reveal good days or bad days about specific events or social interactions that may also trigger the desire to eat or vomit.

When treating eating disorders, it is important to consider working with patient’s family as an important part of the treatment approach, especially when treating the adolescent population. Vandereycken and Vanderlinden in 1989 in the publication The Family Approach to Eating Disorders discuss the use of family-oriented strategies such as a hierarch of approach from simple patient education to more intensive treatment and also constructive collaboration to meet the family’s needs to the extent that they are ready for it. The authors caution not to blame the family and to offer support. They also advise to distinguish between families in temporary crisis form those with more chronic pathological functioning. In order to accomplish the latter, Vandereycken et al. suggest a pyramidal model of family counseling with four levels:

  • Level 1- guidance and education for all parents
  • Level 2- family therapy for several from Level 1
  • Level 3- marital therapy for some from Level 2
  • Level 4- individual therapy for either parent for a few from Level 3 The interventions of Level 1 and 2 can focus on strengthening joint parental authority in the family in order to restore competence and effectiveness and to acquire new problem-solving and child rearing skills.

In conclusion, treating eating disorders and the obsessive-compulsive behaviors and thoughts that accompany them, can be a very complex and challenging task for a psychologist. Whether developing a sound treatment approach, working with other professionals within the community, or engaging both the patient and family effectively, it is important that the psychologist be both nurturing and authoritative. In his 1991 publication, Levenkron speaks of the nurturant –authoritative approach as a balanced role which embraces both care and support together with authority and expertise. This is definitely not an easy task but presents itself as a model for the treating psychologist to work towards.