December 4, 2011

OCD and eating disorders

There is a really interesting conversation going on right now on Around the Dinner Table about obsessive compulsive symptoms and eating disorders. As usual, some very bright parent minds are being applied to the topic:

Subject: The relationship between EDs and OCDs

13 comments:

  1. I definitely feel that for me, AN was a form of OCD, because when it started it didn't really feel much different to the intrusive thoughts and compulsive behaviours I had experienced from early childhood. Therefore, it's difficult for me to see AN and OCD as being separate.

    However, I also had a very high number of obsessive-compulsive personality traits from being a small child, so these also fed into both my OCD and AN. As far as I'm concerned, they're all brain quirks, but triggered by environmental factors and personal experiences. Some things that didn't bother other kids greatly bothered me, and I had so many phobias as a kid.

    I don't feel anorexic any more. All those fears and obsessions have gone, but only to be replaced by different fears and obsessions... I don't care about calories in food or what I weigh (unless I lose weight inadvertently through illness when I am worried that I won't be able to regain lost weight). I do still have OCD and an obsessive-compulsive personality, just as I had pre-AN... *Sigh*

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  2. This is relevant to me, because looking back now, I am certain I had child-onset OCD. The OCD and ED definitely feed each other.

    (The post above me - I could have written the exact thing, lol.)

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  3. I'm with both of you. I have asked ED experts to explain to me why EDs (and BDD) are NOT considered OCDs and not had a good answer aside from "PLEASE don't make us start over from scratch we've fought so hard for what we've got!"

    It has been obvious to me from the beginning that the intrusive thoughts and behavioral compulsions and the checking and the counting and the dichotomous thinking and set-shifting and all the qualities of eating disorders (and BDD) are no different than in frank OCD - except in that the thoughts/behaviors are around feeding and body schema and that they are often barely or not at all seen until there is an energy imbalance - even a small deficit. Restoring normal eating and behaviors around food brings those obsessive thoughts closer to "normal" for many, and for some if caught early sometimes indistinguishable from normal.

    Those who have very strong OCD cognitions in addition to the ED-related ones (pre-ED onset or remaining after ED) strike me as having a more global OCD pattern.

    I also note that many OCD sufferers "self-medicate" by staying at a "safe" but not optimal body composition - or have rigid and unusual dietary patterns - and wonder how many would have a different OCD outcome if maintaining optimal dietary and body composition levels. Just as those with mood disorders may use alcohol or drugs to manage their symptoms, I have to wonder how many OCD sufferers unconsciously "use" diet to do the same?

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  4. Hi Laura,
    I wonder if it makes more sense to think of them on the anxiety disorder spectrum rather than in the specific box of OCD? My daughter has generalized anxiety and social phobia but she's not OCD...and I don't think she's the only one like that....

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  5. Interesting question above, Laura. Although I feel that AN is driven largely by energy deficit, I'm not sure that this is the same for OCD in general, or for someone who had OCD before they developed AN. And there is also the issue of whether the OCD is part of a broader spectrum of unusual cognition; e.g. the autism spectrum.

    From a personal perspective, the lower my weight was, the less intense was my OCD in other areas of my life - because when very sick with AN, all my focus was on my eating and exercise rituals. As I gained weight, I seemed to unconsciously 'replace' the anorexic fears with unrelated fears and associated behaviours - especially contamination fears which still dominate my life. I have difficulty eating out nowadays because of a fear of eating contaminated food; not a fear of the calorie content of the food. If out-and-about in the city without my own pre-packed food and faced with the choice of buying a piece of unwashed fruit vs. a wrapped chocolate bar I will buy the chocolate bar - because it's less likely to be contaminated. The idea that someone else has had their 'paws' over my food totally horrifies me.

    I would suggest, from my personal perspective at least, that any 'self-medication' is to avoid general anxiety and uncertainty. My OCD has worsened and become broader with weight gain and better nutrition. I also have family members with OCD who are very well nourished.

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  6. I love this conversation!

    Anonymous, well, I agree with the larger umbrella here - as OCDs are anxiety-related as well. Perhaps put OCDs under anxiety and EDs as a sub-category of anxiety disorders?

    Cathy, your description fits this well. You describe obsessions and anxiety related to them. You describe the anxiolytic effects of lower nourishment. We also know that there is a rebound effect when someone has been undernourished so that anxiety is FAR HIGHER in those who have had that refuge of low nourishment for a while - and unless they press past that barrier and stay there a while, which is agonizing.

    Could I propose that your OCD symptoms around food are something you have in the past self-medicated with low nourishment (eating less reduced the anxiety) and exercise rituals but when you no longer used those behaviors you still had that anxiety and those fears and behaviors to cope with.

    I characterize the food avoidance and rituals of EDs as self-medication for anxiety and obsessions - a grueling and self-perpetuating trap that the person "explains" in a range of ways (in our society they are most likely to explain it as a desire to be thin, as those are common values in our society). For some, getting all the way out of the malnourishment quickly AND getting treatment for the anxiety and obsessions is effective. For others, the latter symptoms are "trait, not state" and treatment needs to continue.

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  7. I totally agree, Laura. In my post 'Body Image and Anorexia Nervosa' (http://extralongtail.wordpress.com/2011/11/18/body-image/) I described how my body checking, measuring and weighing when at a low weight in my teens were related to a fear of seeing and experiencing CHANGE. I was frightened of seeing the number on the scale rise and the measurements of (e.g.) my thighs increasing because this signified CHANGE. At that point in time it was very difficult for me to articulate my feelings or make sense of them, so when queried about my behaviours I would just say "I'm frightened of getting fat." But what made me anxious was actually CHANGE - which is very difficult for kids with rigid thought patterns, low novelty seeking, harm avoidant.... i.e. everything that I was, and actually still am. Vanity/beauty didn't enter the equation whatsoever.

    These characteristics in me are trait rather than state. That is why I have benefitted from continued therapy. I perceived my existence to be utter chaos once I had gained > 30 pounds. Having maintained that weight gain for > 3 years, I am less rigid in many areas of my life, I have no obsessive behaviours around weight or body checking and I certainly don't feel 'fat'. If something happens in my life that makes me (even) more anxious than usual my immediate urge is to restrict and/or to over-exercise - because these behaviours bring immediate relief of anxiety. But I know I have to resist the urge to restrict food in particular.

    So yes, as far as I'm concerned, it is anxiety that lies at the root of many of my mental health difficulties.

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  8. P.S. Laura, you write above: "I have asked ED experts to explain to me why EDs (and BDD) are NOT considered OCDs and not had a good answer aside from "PLEASE don't make us start over from scratch we've fought so hard for what we've got!"

    They've fought so hard for what we've got, but is what we've got good enough?

    IMO there has been a lot of 'fluff' published about EDs over the past 30 years - with far, far, far too much emphasis on 'body image', feminist theory, families as being the apparent cause, psycho-sexual stuff (etc. etc.).

    When I was diagnosed with AN in the 1970s, AN was considered largely as a physical illness that should be treated by re-feeding. I wasn't psychoanalysed to any great degree. Unfortunately my mother never managed to cope with my reaction to being re-fed and was desperately worried that I would either run away or kill myself if she pushed me any further. I did gain weight, but not enough even to menstruate.

    I just wonder whether some of the 'fluff' that has been published about EDs over the past 30 years has merely created confusion, red herrings and in some cases worse treatment.

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  9. Extra, I wonder that myself. I dream of some definitive scientific breakthrough that all of a sudden puts EDs in another category altogether and we just have to start from scratch and not place anything old into evidence unless it fits the new paradigm!

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  10. okay, anonymous back again. How about eating disorders are seen as consequences or complications of anxiety disorders in general or more specifically OCD, GAD, etc???

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  11. I know I'm late to the party, but weirdly in the UK BDD IS categorised with OCD. They share a NICE guideline: http://www.nice.org.uk/CG31

    So why eating disorders aren't included I really couldn't say. Because of the greater need for medical management and risk of complications, maybe? Maybe it would be too complex and long-winded to put them in the same guideline as well...

    Personally I don't think I have OCD, I think I have OCD-like personality traits, maybe even low-end ASC traits. But when I was anorexic I had the exact opposite reaction to Cathy - I became more and more obsessive in all other areas of my life rather than less so. Now I'm at a healthy weight I'm not nearly as obsessive and ritualistic about anything.

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  12. Anonymous, you need a handle!

    It strikes me that OCD, BDD, GAD, ED are all dimensions of thoughts and behaviors - each person has a different profile of these qualities and they affect one another. ED behaviors, just like OCD rituals, function like "answers" to anxious and uncomfortable emotions - but in the case of ED behaviors the biological effects serve to perpetuate the behaviors and thoughts.

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  13. Oh dear, I am so late to this discussion. So late. I hope you are all still around. To be honest, I have thought for a long time about an, in particular, being an anxiety condition. I also think that the ed classification as a seperate disorder is a load of bollox. The anxiety is terribly distressing and continues after eating issues are gone. Without treating the anxiety, other compensatory behaviours creep in and the chance of relapsing to compensatory eating behaviours, which have alleviated the anxiety in the past, is high. Here speaks a smoker.....

    Many of you here know that I am on a bit of crusade to end this tick box approach to mental illness. I get so "Gah" about the whole "she's got depression as well as this and that and the other". The brain is sick - it is not well and is manifesting its distress in a myriad of signs and symptoms. There are too many similarities and cross overs between too many conditions for them all to be seperate.

    At the moment, we are treating end stage symptoms. Fine. That is what we have to deal with as science has not progressed enough to help us deal with it any other way. However, this dealing with one thing at a time or not recognising that various conditions are tied to each other (anxiety and eating disorders, OCD and anxiety/asc conditions, depression and addiction - the list goes on) and are interchangeable at any stage of treatment is where we fall down, IMHO.

    If relieving that anxiety of refeeding with anti anxiety medication or appropriate therapy helps an ed patient to recover physically, why aren't we doing it more? Why are we talking about anxiety alongside ed, as if they were two seperate conditions. Having refed my d, I can know see that if I had understood it was more about the anxiety than the food, it would have made me less combatative and unfeeling.

    Sigh. It is time for all these specialists to see outside their boxes and start talking to each other. I am not just talking about ed specialist btw....xx

    PS I hate laura's new blog layout because it has forgotten who I am so I am going to have to be Anon as well but I am CHARLOTTE BEVAN

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