OCD, Eating Disorders, & ERP
Updated: May 9
By: Breanna Potts M.S.
According to the International OCD Foundation, 69% of people with eating disorders also experience symptoms of OCD, where 41% are diagnosed with both OCD and an eating disorder. However, we suspect these numbers may be higher due to shame and under reporting. OCD stands for Obsessive Compulsive Disorder and it is when a person struggles with obsessions and compulsions. Now you might hear, “obsessions,” and think, “I’m obsessed with this new TV show” or “reading is my new obsession!” When it comes to OCD, these obsessions are not a spiked interest in a new TV show or a new activity. Obsessions in OCD are unwanted and intrusive thoughts, images, or urges that are often extremely distressing to the individual. Not fun at all! Compulsions are the behaviors that an individual engages in to help relieve the anxiety and distress they feel from their obsessions. So, in simple terms, it is this exhausting and vicious cycle of having extremely distressing thoughts, images, or urges, and then engaging in behaviors to make that distress go away. However, the behaviors do not rid a person of the anxiety forever. In fact, it is temporary relief and the obsessions come back, resulting in the person engaging in their compulsions again. At times, leading to a vicious cycle of anxiety and distress.
Everyone experiences intrusive thoughts from time to time, but a person with OCD experiences them to the point where the thought, image, or urge causes an extreme amount of anxiety where they may struggle to move on from the thought unless they engage in the compulsion to relieve the anxiety. When it comes to eating disorders, OCD-like symptoms are more common and in many cases, a person can experience both OCD and an eating disorder at the same time. For example, the urge for things to be “just right” is commonly seen in both eating disorders and OCD. This may be experienced as a strong desire for things to be done in a certain or very particular way and can cause a person to redo simple tasks until it “feels right.” There may be some instances in your life where you like to do things a certain way, such as preferring to pour your cereal before the milk, however, for a person with OCD, preference is putting it very lightly. They feel an intense need to do things in a very rigid way. A person struggling with an eating disorder may cut their food into small pieces, but a person with an eating disorder and OCD may cut their food into small pieces and feel the need to arrange the food in a specific way on their plate that “feels right” before eating it. Or, may feel the need to cut their food into small pieces, but in an even number of pieces, or a number that feels safe or right to them. Another common overlap in eating disorders and OCD is body checking. A person with an eating disorder may check their body when they pass by a mirror, but a person with an eating disorder and OCD may feel a very strong and distressing urge to check their body after a meal in a very ritualistic way where they follow the same checking routine each time due to a belief that doing so will “undo” or “prevent” them from gaining weight. These ritualistic behaviors are compulsions and are done in an attempt to alleviate anxiety. There are many other ways OCD can present in a person with an eating disorder and these examples are not the only ones! It can be really tricky to differentiate when a behavior is due to an eating disorder or OCD, so it is important to learn what is driving your behaviors! By uncovering why you engage in certain ritualistic behaviors, you can access the right treatment for what you are going through!
When treating eating disorders, we use an eclectic clinical approach, however with both OCD and eating disorders, Exposure and Response Prevention (ERP) is an evidence-based best practice. ERP is the gold standard when treating OCD. ERP is a type of therapy that exposes you to your fears in a safe and controlled way with the goal of increasing anxiety to help you learn how to tolerate the anxiety without using rituals, avoidance, or compulsions. Think of your anxiety as an alarm system; when you encounter something that makes you anxious, your brain begins sending off “alarms” alerting you that you are in danger. When this alarming happens, you do something about it, right? Who would choose to sit in the middle of danger?! We get it! But there is a difference between actual danger and perceived danger. When it comes to OCD, your brain thinks there is danger everywhere, even if YOU rationally know there is only the slightest chance that you could be in actual danger. Because OCD is constantly functioning in danger-mode, it tries to protect you by giving you lots of ideas of ways to protect yourself…cue the compulsions. Engaging in compulsions is basically like telling your OCD, “thanks for the heads up, we really dodged a bullet there” and thus perpetuates the cycle so that next time there is perceived danger, your brain responds in this panic, alarmed state again. In ERP, we work to help retrain your brain to learn that not every event is a threat and the behaviors your OCD thinks you need are likely very over the top for what is actually happening around you. So, it might seem like ERP is essentially signing yourself up to be in the front line of danger, but that is not what it is! Your OCD will think of ERP as the greatest betrayal of all, but that’s because your OCD is trained to see threats everywhere. In ERP, you are not signing yourself up to be in danger. You are signing yourself up to be able to notice and accept that a bird tapping on your window is not the same as a real burglar breaking into your home.
So, what exactly does ERP look like? ERP looks like you and your therapist creating a detailed exposure hierarchy which is when you list situations that bring you anxiety and then rate those experiences from least amount of anxiety to most amount of anxiety. Together, you and your therapist will work through this hierarchy starting from your least feared situations. This work is called exposures! Exposures will elicit anxiety and you will learn how to tolerate the distress and uncertainty you are feeling without using compulsions. Essentially, in ERP you are learning to allow distressing, intrusive thoughts as they come, without trying to make them go away, reverse them, or simply not have them. When you have an intrusive thought, OCD wants to make it go away by using behaviors such as avoidance, asking for reassurance, rumination, or other compulsions. While engaging in these behaviors does decrease anxiety temporarily, it is actually perpetuating the cycle because the obsessions and intrusive thoughts will come back and the cycle will continue, often with the compulsions becoming more intense, or taking longer to complete. When you engage in compulsions to temporarily alleviate your anxiety, it is essentially feeding your OCD and making it bigger. For example, you may have an intrusive thought that the dinner you just ate made you gain 10 pounds and this thought is very distressing to you and brings up a strong urge to go weigh yourself immediately. So, you weigh yourself to check if you gained 10 pounds and you see that you didn’t gain 10 pounds and then the anxiety goes down. Each time you engage in this cycle of obsession-compulsion, it grows. After engaging in this cycle for a while, it might start to feel like it is not enough, so now you might weigh yourself and engage in body checking, or you may weigh yourself a certain number of times that “feels right” but may find yourself starting over multiple times because you didn’t step on the scale the “right” way. The obsession-compulsion cycle often takes up a lot of time and is very frustrating and distressing for the person suffering. In ERP, your therapist will challenge you to allow the anxiety to rise and essentially do the opposite of what your OCD and eating disorder want you to do. So, this means you will learn to allow the intrusive thought that you gained 10 pounds to arise and accept the uncertainty that maybe you did or maybe you didn’t, but that engaging in your compulsions associated with this obsession is unnecessary as there is no real threat or danger. Gaining 10 pounds is not a true danger; it is a perceived danger that your OCD and eating disorder want you to avoid happening. ERP will challenge you to refrain from rationalizing the situation and seeking reassurance that your fear is not going to come true. You might be thinking, “this sounds a little messed up” and we totally understand why someone may think that! You are being asked to engage in your fears and not do “anything” to avoid facing this fear…it does sound harsh! But, ERP is not done to make your life more miserable or make you suffer more than you already are. While you will likely feel worse than if you were to just engage in compulsions, this is only for a short amount of time. ERP causes short-term pain for long-term gain! Giving into compulsions causes short-term gain and long-term pain. This may sound super uncomfortable and scary…and that’s okay! It is scary to face your fears, but it will get easier as you move through the exposures! Treatment is tailored to YOU and your therapist should approach this work with you gently and compassionately! It is hard and your therapist should challenge you, but you can absolutely do hard things! Lastly, you move through the hierarchy at your pace! There is no time limit…this is your recovery and recovery is possible for you! For more information about OCD and eating disorders and the use of ERP as treatment, check out the resources below!
What is OCD?: https://iocdf.org/about-ocd/
The Relationship Between Eating Disorders & OCD: https://iocdf.org/expert-opinions/expert-opinion-eating-disorders-and-ocd/
Using ERP to Treat OCD & Eating Disorders: https://iocdf.org/expert-opinions/treatment-of-obsessive-compulsive-disorder-with-comorbid-eating-disorders/
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Recovered and Restored is an eating disorder therapy center founded by Gabrielle Morreale. We specialize in helping teens and young women heal from eating disorders such as anorexia, bulimia, orthorexia, and binge eating disorder and treat disordered eating, anxiety, depression, and PTSD. We provide eating disorder therapy in the towns of Horsham, Upper Gwynedd, Lower Gwynedd, North Wales, Lansdale, Hatfield, Blue Bell, Doylestown, and nearby towns with eating disorder therapy. Also providing virtual eating disorder therapy in New Jersey, Delaware, and Florida. Some towns served virtually but are not limited to Pittsburg, Lancaster, Harrisburg, Center City, Cherry Hill, Haddonfield, Mount Laurel, Cape May, Avalon, Brick, Dover, New Castle, Bethany Beach, Marydel, and Oceanview.