When OCD attacks Eating

Every so often a new client comes to me with the statement, "I think OCD is attacking my eating." Yes, you are right. OCD and Eating disorders can co-occur. While each individual is unique, I think it is worth discussing and understanding the general overview of the topics.

OCD and Eating Disorders:

Both OCD and eating disorders are rooted in intrusive thoughts, rigid rules, and compulsive behaviors. While OCD is typically defined by obsessions (unwanted, distressing thoughts) and compulsions (repetitive behaviors or mental acts aimed at reducing distress), eating disorders like anorexia nervosa, bulimia nervosa, and ARFID (Avoidant/Restrictive Food Intake Disorder) also involve intrusive fears and ritualistic behaviors around food, body image, and control.

Common overlaps include:

• Perfectionism and fear of imperfection

• Ritualistic eating patterns (e.g., cutting food into precise pieces)

• Contamination fears related to food or body

• Intrusive thoughts about body image or weight

• Compulsive exercise or checking behaviors

It’s not uncommon for clients to say things like, “I can’t eat unless I prepare my food in exactly the right way,” or “If I eat this, something bad will happen.” These are not just habits—they are safety behaviors rooted in anxiety and maintained by avoidance, which is central to both OCD and eating disorders.

When OCD and Eating Disorders Co-Occur

When a client presents with both OCD and an eating disorder, the conditions can reinforce one another. For example:

• A person with contamination OCD may severely restrict food due to fears of germs, overlapping with ARFID or anorexia.

• Someone with symmetry/ordering OCD may only allow themselves to eat certain foods in a specific order or proportion.

• Body-focused obsessions may feed into compulsive body-checking or restrictive eating behaviors.

Unfortunately, clients with this comorbidity often fall through the cracks because treatment is complex. An eating disorder specialist may not be equipped to treat OCD, and vice versa. That’s why an integrated approach is not only beneficial—it’s essential.

Treating the Overlap with Exposure and Response Prevention (ERP)

Exposure and Response Prevention (ERP) is the gold-standard treatment for OCD and is increasingly being adapted for use with eating disorders, especially when OCD traits are present. ERP works by helping clients gradually face feared situations (exposure) while resisting the urge to engage in compulsive behaviors (response prevention).

How ERP Can Be Applied to Eating Disorder Behaviors:

1. Identifying Core Fears and Rituals:

   • For example: “If I eat carbs, I will gain weight and lose control.”

   • Or: “If my food touches, I will get sick.”

2. Creating a Hierarchy of Challenges:

   • This might include eating “feared” foods, breaking rigid food preparation rituals, or tolerating the uncertainty of not checking one’s body in the mirror.

3. Conducting Exposures:

   • Under guided, supportive conditions, clients practice eating in ways that defy their rules while resisting compensatory behaviors (e.g., restricting later, over-exercising, body checking).

4. Response Prevention:

   • Clients learn to sit with the anxiety and intrusive thoughts without performing rituals. Over time, this weakens the obsessive-compulsive cycle and increases psychological flexibility.

ERP for OCD vs. ERP for Eating Disorders: Important Nuances

While the structure of ERP remains consistent, there are some key differences when addressing eating disorders:

• Medical stability must come first. For clients with anorexia or severe malnutrition, ERP may need to be delayed or modified until they are physically stable.

• Nutrition support and collaboration are vital. A multidisciplinary team—often including a dietitian, physician, and therapist—is best practice.

• Values work can enhance ERP. Many clients benefit from integrating Acceptance and Commitment Therapy (ACT) or values-based interventions to increase motivation and long-term recovery.

Final Thoughts: Treating the Whole Person

As an LCSW specializing in OCD, I see firsthand how rigid rules and compulsions can dominate a person’s life—whether they center around hand-washing or food choices. By using ERP to treat both OCD and eating disorder symptoms, we give clients the tools to challenge fear-based behaviors, expand their tolerance for uncertainty, and ultimately reclaim freedom over their lives.

If you or someone you care about is struggling with OCD, an eating disorder, or both, know that recovery is possible—and it starts with the right treatment.