The Link Between Eating Disorders and OCD: How ERP and ACT Promote Recovery

Between 33-44% of individuals with eating disorders also experience obsessive-compulsive disorder (OCD). Both OCD and eating disorders share maladaptive behaviors such as obsessive thoughts about weight and ritualistic eating habits. Treatment options like Exposure and Response Prevention (ERP) and Acceptance and Commitment Therapy (ACT) help manage both OCD and eating disorder symptoms, offering a path toward recovery for those affected by both conditions.

Obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is the presence of obsessions (recurrent and persistent thoughts, urges or images that are intrusive and unwanted), compulsions (repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession) or both.¹

Obsessions or compulsions can be time consuming, cause significant distress or impair important areas of functioning.

The Link Between OCD & Eating Disorders

Up to 44% of those with anorexia nervosa and atypical anorexia nervosa and up to 33% of those with bulimia nervosa also have OCD.^2,3  The relationship between OCD and eating disorders may be reciprocal, with studies suggesting that OCD symptom improvement follows eating disorder symptom improvement.⁴

"Eating disorders and obsessive-compulsive disorder frequently coexist, driven by a shared need for control and ritualized behaviors in response to anxiety," says Kamila Cass, PhD, CEDS, clinical psychologist at ACUTE, "Their intersection highlights how anxiety can manifest through both mental and behavioral rigidity."

Obsessions & compulsions in eating disorders

The pathological presentation of OCD is mirrored in anorexia nervosa. Repetitive behaviors to perform certain acts, obsessive and persistent thoughts and compulsive behavior to reduce stress are also present in disordered eating behaviors. Patients often:

• Present with persistent and obsessive thoughts about weight loss or preventing weight gain
• Repeatedly measure their weight, perform body checks or recheck portion sizes, calories or micronutrients
• Exhibit ritualistic behaviors while eating, like cutting food into small pieces, arranging food, eating foods in a specific order, weighing and measuring food in certain quantities or disassembling food

Exposure & Response Prevention for OCD

The gold standard treatment for OCD is exposure and response prevention (ERP). ERP is effective by itself, but produces better outcomes in combination with psychotropic medication.^5,6 ERP gradually exposes individuals to situation or thoughts that trigger the OCD anxieties while a therapist helps them in session or assigns homework to the individual to prevent them from engaging in the usual compulsive behavior. While this treatment is uncomfortable, it can reduce the power of obsessions and compulsions, allowing the OCD symptoms to be better managed. Finding a treatment provider who specializes in OCD as well as other treatment resources can be found on the website for the International OCD Foundation: https://iocdf.org/

Acceptance and Commitment Therapy for OCD

Acceptance and commitment therapy (ACT) is an evidence-based form of psychotherapy that aims to develop psychological flexibility instead of avoiding, eliminating or suppressing undesirable experiences. ACT can help patients accept their OCD obsessions rather than trying to fight or control them, and can help individuals commit to actions aligned with an individual’s personal values, allowing them to live a more fulfilling life despite their OCD symptoms. ACT has not outperformed traditional ERP but is comparable to ERP when it is combined with pharmacotherapy, and can be an alternative treatment for individuals who were not responsive to ERP treatment.⁷

Learn more about psychotherapy for eating disorders here.

Find Help for Dual Diagnosis

Living with both an eating disorder and OCD 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. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
2. Levinson, C. A., Brosof, L. C., Ram, S. S., Pruitt, A., Russell, S., & Lenze, E. J. (2019). Obsessions are strongly related to eating disorder symptoms in anorexia nervosa and atypical anorexia nervosa. Eating Behaviors, 34, 101298. https://doi.org/10.1016/j.eatbeh.2019.05.001
3. Matsunaga, H., Kiriike, N., Miyata, A., Iwasaki, Y., Matsui, T., Fujimoto, K., Kasai, S., Kaye, W. H., & Kaye, W. H. (1999). Prevalence and symptomatology of comorbid obsessive–compulsive disorder among bulimic patients. Psychiatry and Clinical Neurosciences, 53(6), 661–666. https://doi.org/10.1046/j.1440-1819.1999.00622.x
4. Olatunji, B. O., Tart, C. D., Shewmaker, S., Wall, D., & Smits, J. A. (2010). Mediation of symptom changes during inpatient treatment for eating disorders: The role of obsessive–compulsive features. Journal of Psychiatric Research, 44(14), 910–916. https://doi.org/10.1016/j.jpsychires.2010.02.011
5. Reid, J. E., Laws, K. R., Drummond, L., Vismara, M., Grancini, B., Mpavaenda, D., & Fineberg, N. A. (2021). Cognitive behavioural therapy with exposure and response prevention in the treatment of obsessive-compulsive disorder: A systematic review and meta-analysis of randomised controlled trials. Comprehensive psychiatry, 106, 152223.
6. Del Casale, A., Sorice, S., Padovano, A., Simmaco, M., Ferracuti, S., Lamis, D. A., ... & Pompili, M. (2019). Psychopharmacological treatment of obsessive-compulsive disorder (OCD). Current neuropharmacology, 17(8), 710-736.
7. Philip, J., & Cherian, V. (2021). Acceptance and commitment therapy in the treatment of Obsessive-Compulsive Disorder: A systematic review. Journal of Obsessive-Compulsive and Related Disorders, 28, 100603.