OCPD, OCD, and Eating Disorders: How Comorbid Diagnosis and Treatment Works
Written by CCTC Staff Writer
Eating disorders are difficult to treat on their own. Often, though, an eating disorder isn't a person’s only mental health problem. A lot of people with an eating disorder meet diagnostic criteria for another disorder (known as a comorbid disorder). Many people have comorbid obsessive compulsive disorder (OCD) or obsessive compulsive personality disorder (OCPD).
Because eating disorders, OCD, and OCPD show up together so often, you have to wonder whether there’s a relationship between them. Read on to find out more about OCD and OCPD, why they may be related to eating disorders, and how eating disorder treatment professionals treat comorbid disorders.
What is a Comorbid Diagnosis?
A person who has two or more mental health disorders has a comorbid diagnosis, or a co-occurring disorder. They show symptoms of two or more distinct disorders.
There are several things to consider when making a comorbid diagnosis:
Did both disorders manifest at the same time, or did one occur right after another?
Does one disorder feed into another?
Are there genetic or environmental factors that can contribute to two disorders? For example, smoking and alcohol consumption are correlated (they are both substances that a person may overuse.) The first one can cause lung diseases, and the second can cause liver disease.
Are two disorders related to one distinct, impactful disorder? For example, an eating disorder and substance use disorder can both stem from undiagnosed trauma.
Diagnosing a comorbid disorder is not easy. For example, when being treated for an eating disorder, your anxiety skyrockets. Treatment professionals have to decide whether you are suffering from an anxiety disorder, are experiencing clinical anxiety because of treatment, and whether one caused the other.
What is Obsessive Compulsive Disorder (OCD)?
Obsessive compulsive disorder is defined as the presence of an obsession (an irrational thought or idea that repeats continually) and/or compulsion (an irrational behavior done repeatedly).
OCD is commonly misrepresented in the media, OCD being portrayed as a quirky personality trait instead of a debilitating disorder. (But there are a few TV shows that capture the difficulty of living with OCD.) So let’s break down what “obsessions” and “compulsions” are on a clinical level.
Obsessions are:
Irrational thoughts, images, or ideas that won’t go away, are unwanted, and cause extreme levels of distress
These thoughts, images, or ideas are distressing to the point that sufferers are compelled to do something about them, like using unhealthy compulsive behaviors to make them go away
Compulsions are abnormal behaviors, which may include:
Repeating irrational, often highly ritualistic behaviors such as hand washing, counting, tapping on objects, and “double checking” things, despite having checked them several times throughout the day
Engaging in behaviors because a sufferer believes that something terrible may happen if they don’t
Hoarding items out of the fear that something bad will happen without the items being near
Engaging in behaviors to dispel obsessive, anxiety inducing thoughts such as potential illness, the destruction of property, or the death of a loved one
What is Obsessive Compulsive Personality Disorder (OCPD)?
Obsessive compulsive personality disorder is characterized by the need to maintain rituals and routine so that sufferers can control their environment and relationships. Those suffering with OCPD need such a rigid structure because they have an overwhelming need for order, control, and perfection.
OCPD is also commonly misrepresented in the media. An extremely organized leader planning an event for a committee does not automatically qualify as OCPD (although a person with OCPD may find themselves in a situation like this.)
There are nine distinct personality traits related to OCPD. You must have at least four of them in your early adulthood to be diagnosed with OCPD:
Preoccupation with lists, details, schedules, organization
Striving to do an activity or assignment so well that you end up procrastinating on it, and possibly not finishing at all
Excessive preoccupation with work or productivity (not related to any financial difficulty) that negatively impacts your personal interests and relationships
Extreme conscientiousness and inflexibility when it comes to moral values (a common example when it comes to eating disorders: refusing to eat nonvegan foods, despite having absolutely no access to vegan alternatives)
Unwillingness to throw out old items, even if they have no practical use or sentimental value
Reluctance to delegate tasks to others unless they agree to do it exactly as they’re told to
An extremely stingy, unhappy approach to spending money, as you see money as something to be saved for future disasters
While both OCD and OCPD involve the use of rituals to calm anxiety, they are two different disorders. People with OCD understand their rituals as disordered, while people with OCPD often don’t. This makes sense: society values extreme productivity and organization. But those with OCPD have interpersonal problems, lose out on life experiences, and feel physical and mental burnout.
Co-occurring OCD, OCPD, and Eating Disorders
Researchers have not yet found a direct relationship between OCD and eating disorders, or OCPD and eating disorders. But they have theories about these comorbid disorders.
Comorbidity of OCD and Eating Disorders
Several studies have been done to evaluate people with eating disorders for different OCD symptoms and behaviors. In this large study, OCD symptoms such as difficulty controlling thoughts, compulsive checking, and fears about potential consequences of not engaging in compulsive behaviors were often found in those with eating disorders. Some people with binge eating disorder also showed symptoms of hoarding.
Other common features of OCD and eating disorders:
The irrational fear of a possible future self (for instance, the fear of becoming someone who has “lost control” if they eat normally)
The confusion between reality and an imagined reality (for example, having such a strong irrational belief about gaining weight when eating despite evidence proving otherwise)
Possible underlying genetic factors contributing to both OCD and eating disorders
Comorbidity of OCPD and Eating Disorders
At its core, OCPD is about perfectionism, rigidity, and the overwhelming need to control one’s environment. These are also commonly found in some individuals with an eating disorder.
These character traits are common underlying features of both disorders. Individuals with OCPD feel the need to control everything, even food. They will go to great lengths to satisfy their need to build the “perfect” body (which is, of course, impossible.)
OCPD can be related to eating disorders because of shared personality traits.
Related: Learn more about perfectionism and eating disorders here.
Why is it so Hard to Treat Co-occurring Disorders?
When being treated for one disorder, a co-occurring disorder may become much worse. This is because many people engage in eating disorder behaviors to manage another disorder. For example, you may use overexercise as a way to escape depressive thoughts and feelings. Once you stop exercising, your depression becomes much worse.
For some people, when eating disorder coping mechanisms are taken away, a comorbid disorder may become so distressing that a person may use other dangerous coping mechanisms to numb out from all those feelings.
If you are someone with a co-occurring diagnosis, facing challenges from all directions can make recovery feel impossible, unbearable, or just not worth it. If you always have to live with these disorders, it’s easy to feel discouraged.
But treatment providers have developed ways to treat co-occurring disorders.
Eating Disorder Treatment with Co-occurring OCD or OCPD
OCD, OCPD, and eating disorders all involve rituals and control. Taking away control over food is much harder for someone who is as compelled to perform rituals as someone with co-occurring OCD or OCPD. They may develop compulsive behaviors in other areas in order to regain control. This includes extremely “healthy eating,” overexercise, and purging behaviors.
The best way to treat co-occurring disorders is to treat them all at once.
The medical and behavioral aspects of an eating disorder must be managed first, though. This includes becoming medically stable, taking in sufficient nutrition, and reducing more physically damaging eating disorder behaviors such as binging, purging, and overexercise. (If your body is not being taken care of, you can’t even begin to take care of your mind.)
Eating disorder treatment practices that are also effective for OCD and OCPD:
Cognitive behavioral family, to challenge distorted thoughts that cause compulsions
Exposure therapy, to disprove irrational beliefs and grow comfortable with giving up control
Researchers have also proposed a transdiagnostic approach to treating individuals with co-occurring disorders. This means that eating disorder treatment professionals would not try to treat the specific disorders. Instead, they would treat the common factors that contribute to both disorders.
For example, an individual with OCD and an eating disorder struggles with intrusive thoughts, so a treatment professional would address that. An individual with OCPD and an eating disorder struggles with perfectionist tendencies, so treatment would revolve around breaking perfectionistic thoughts and tendencies.
Related: Not sure what to consider when looking for an eating disorder therapist? Click here.
If you are seeking treatment for an eating disorder, and know that you struggle with another disorder, it’s important to find a treatment provider or center prepared to treat both at the same time. It’s very likely that recovering from your eating disorder will make a co-occurring disorder harder to manage. So you have to be somewhere prepared to treat any and all problems you may face.
If you or a loved one is suffering from an eating disorder, take the first step today and talk to someone about recovery or simply learn more about the holistic eating disorder recovery programs we offer.