Eating Disorders and Personality Disorders: How BPD and OCPD Influence Disordered Eating

By Jamie Manwaring, PhD

Personality disorders, including borderline personality disorder and obsessive-compulsive personality disorder, affect up to 37% of those with eating disorders. Traits like perfectionism, impulsivity, emotional dysregulation and rigidity contribute to disordered eating, including restriction, binge eating and purging. Therapies like dialectical behavior therapy (DBT) and radically open DBT support self-esteem, emotion regulation and recovery.

Eating Disorders and Co-occurring Personality Disorders

Known as dual diagnosis, research demonstrates that up to 95% of people diagnosed with an eating disorder also receive a diagnosis for at least one more psychiatric disorder.1 Personality disorders are the third most common comorbid group of psychiatric disorders among eating disorder patients, affecting up to 37% of those with eating disorders.2 Individuals with bulimia nervosa are more likely to have a personality disorder than those with anorexia nervosa.

Obsessive-compulsive Personality Disorder

Obsessive-compulsive personality disorder (OCPD) is a pervasive pattern of preoccupation with orderliness, perfectionism and mental and interpersonal control at the expense of flexibility, openness and efficiency.3 It can be presented through:

  • Preoccupation with details, rules, lists, order, organization or schedules
  • Perfectionism that interferes with task completion
  • Over conscientiousness, scrupulousness and inflexibility
  • Reluctance to delegate tasks
  • Rigidity and stubbornness

OCPD & eating disorders

The prevalence of OCPD is much higher in patients with eating disorders. OCPD is present in 22% of individuals with anorexia nervosa restricting subtype (AN-R), compared to 8% in the general population.4

Many of the characteristics of OCPD are mirrored in eating disorder pathology. A preoccupation with details, rules, order and schedules easily facilitates disordered eating behaviors like:

  • Strict calorie and micronutrient counting
  • Rigid exercise schedules
  • Precision dieting
  • Dedication to achieving lower weights or specific measurements.

How is OCPD linked with eating disorders?

The perfectionism characteristic of OCPD complements the thin ideal and can contribute to disordered eating behaviors. Those with OCPD are prone to strict regimens, which can help maintain a complex eating and exercise routine and help one commit to severe restriction.

Excessive devotion to work can fuel an intense focus on weight loss at the expense of other areas of life, which is often seen in patients with eating disorders. Inflexibility on morality and values can express itself through idealization of weight loss, low body weight and self-control characteristic of restriction. Rigidity and stubbornness reflect the uncompromising pursuit of weight loss despite the medical risks.

Borderline Personality Disorder

Borderline personality disorder (BPD) is a pervasive pattern of instability of interpersonal relationships, self-image and affects with marked impulsivity.3 Some indicators of BPD include:

  • Frantic efforts to avoid real or imagined abandonment
  • Pattern of unstable and intense interpersonal relationships
  • Identity disturbance
  • Impulsivity in at least two areas that are potentially self-damaging
  • Affective instability due to a marked reactivity of mood
  • Feelings of emptiness

BPD & purging behaviors

The prevalence of BPD is more common in patients who purge. 25% of patients with anorexia nervosa binge eating/purging subtype (AN-BP) and 28% of patients with bulimia nervosa have co-occurring borderline personality disorder, exceeding the general population's rate of BPD at 6%.4

Shared traits between BPD and eating disorders

Some of the characteristics of BPD are also exhibited in eating disorders that involve binge eating and/or purging. The impulsivity categorized by BPD is easily mirrored in impulsive eating pathology. Impulsivity is exhibited through binge-eating episodes as well as purging methods like self-induced vomiting and misuse of diuretics and laxatives.

Purging as self-injury

Purging can also be perceived as a form of self-injury, which is common in patients with borderline personality disorder. It has the possibility of causing significant harm, and at its most severe, can cause serious medical complications or death.

Treating Co-occurring Personality Disorders & Eating Disorders

Multiple therapies have been shown to help people with personality disorders and eating disorders recover and live more fulfilling lives. This includes dialectical behavior therapy (DBT), radically open dialectical behavior therapy (RO-DBT) and trauma-focused therapies: eye movement desensitization and reprocessing (EMDR), cognitive processing therapy (CPT) and prolonged exposure (PE).

Dialectical behavioral therapy

DBT is a form of psychotherapy that focuses on mindfulness, interpersonal relationships, distress tolerance and emotional regulation. It is especially helpful for those that feel emotions very intensely, like those who have co-occurring borderline personality disorder.

Radically open dialectical behavioral therapy

RO-DBT is a form of DBT designed to address disorders with features associated with maladaptive over-control. RO-DBT may be particularly helpful for those with co-occurring anorexia nervosa and OCPD.

Trauma therapies: EMDR, CPT & PE

For personality disorders that have developed at least partially from a trauma history, trauma therapies such as EMDR, CPT and PE may be useful.

Learn more about psychotherapy for eating disorders here.

Find Help for Dual Diagnosis

Living with both an eating disorder and a personality disorder can feel especially overwhelming, but you don’t have to navigate it alone. Integrated care that addresses both conditions at the same time is essential for lasting recovery. With the right support team and evidence-based treatment, recovery is possible.

References

  1. Hambleton, A., Pepin, G., Le, A., Maloney, D., Aouad, P., Barakat, S., Boakes, R. A., Brennan, L., Bryant, E., Byrne, S. M., Caldwell, B., Calvert, S., Carroll, B., Castle, D. J., Caterson, I. D., Chelius, B., Chiem, L., Clarke, S., Conti, J., . . . Maguire, S. (2022). Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature. Journal of Eating Disorders, 10(1). https://doi.org/10.1186/s40337-022-00654-2

  2. Godt, K. (2008). Personality disorders in 545 patients with eating disorders. European Eating Disorders Review, 16(2), 94–99. https://doi.org/10.1002/erv.844
  3. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
  4. Sansone, R. A., Levitt, J. L., & Sansone, L. A. (2004). The Prevalence of Personality Disorders Among Those with Eating Disorders. Eating Disorders, 13(1), 7–21. https://doi.org/10.1080/10640260590893593

ACUTE Earns Prestigious Center of Excellence Designation from Anthem
In 2018, the ACUTE Center for Eating Disorders & Severe Malnutrition at Denver Health was honored by Anthem Health as a Center of Excellence for Medical Treatment of Severe and Extreme Eating Disorders. ACUTE is the first medical unit ever to achieve this designation in the field of eating disorders. It comes after a rigorous review process.

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