If a person visited their doctor and described the following symptoms,
what would you determine their diagnosis to be?
The woman is in her late teens and for the past six months she has been
having problems with eating. When
she eats she must cut her food into very tiny pieces; these pieces are then
counted and separated into foods that are healthy and those which may not be
as healthy on the plate. Once she
has separated the foods she will not eat the unhealthy ones and discards them.
Next she arranges the food in rows on her plate before beginning to
eat. Once eating the food she
only allows herself to have 7 bites of each food item so, as not to
overindulge herself or stray from her set routine because she feels that
something bad will happen if she exceeds this amount. She then proceeds to eat each tiny piece separately chewing
one hundred times for each bite. This
routine is repeated for each meal throughout the day and must be done in the
same way each time. When she is
finished with a meal, which typically takes several hours, she goes about her
daily activities as she does normally and exhibits no other strange behaviors.
it is obvious that the person described above has some issues with her eating
behavior, what exactly is the nature of these issues?
On one hand, she may have an eating disorder.
She is meticulously concerned with the amount of food she is eating and
the health value of each individual morsel of food.
She only allows herself to have a set number of bites and must chew
them thoroughly for the fear that if she exceeds this set amount or style that
something harmful will come to her. These
behaviors are only present when she is eating and have been observed in no
other context, which would lead one to believe that the behavior is tied to
eating specifically. While these
are behaviors that are sometimes present with an eating disorder, just simply
the description of this routine does not in itself specify an eating disorder.
For diagnosis of anorexia or bulimia there must be an intense fear of
gaining weight which is associated with this behavior.
This is not necessarily the case with this person.
Could the problem be obsessive-compulsive disorder?
Counting, checking, ordering and the presence of a strict routine are
symptoms of obsessive-compulsive disorder as well.
Obsessions with checking the food, ordering the food and maintaining
the routine could be the manifestations of this disorder as well.
It is apparent through this example that these two disorders may indeed
have some degree of overlap in symptoms and problem behaviors. Eating
disorders are complicated mental illnesses, which can manifest themselves in
many different areas. While the
most obvious manifestations of an eating disorder are problems dealing with
maintaining body weight and eating behavior, there are many factors, which
underlie these problems with eating behaviors, which are not commonly
publicized. There are many
behaviors that coincide with these bizarre eating behaviors that also deserve
attention. The issue of
comorbidity and eating disorders is an important issue to tackle in terms of
etiology as well as treatment. When
an eating disorder co-occurs with another mental disorder the way in which
treatment may be implemented can be very different.
It is also interesting to look at the eating disorder in the context of
the other mental illness to determine whether the two illnesses are distinct
or whether one heavily influences the presence of the other. This paper will look at the degree of overlap between
obsessive-compulsive disorder and anorexia and bulimia.
By looking at the clinical research, which is being done, to
investigate this linkage it may help us to better understand this relationship
and the implications that it may have in terms of treatment and recovery.
a study by Thornton and Russel (1997) they looked at the relationship between
Obsessive-compulsive disorder (OCD) and all of the dieting disorders. They wanted to test the hypothesis that OCD and the dieting
disorders are ones which often occur together and try to establish this
relationship in the literature. In
this study, they looked at the cases of sixty-eight inpatients that were in
the hospital due to anorexia nervosa and bulimia nervosa.
Thirty-five of these patients had anorexia, and the remaining 33 had
bulimia. These cases were then
analyzed using the DSM III-R Axis I and Axis II to determine whether they
showed symptoms of obsessive-compulsive disorder, or obsessive-compulsive
personality disorder. They were
also assessed for these two disorders using the Composite International
Diagnostic Interview (CIDI), and the Personality Disorders Inventory (PDE).
They used the three measures to provide greater validity for the
results and to tease out cases which indicate a personality disorder or those
which indicate symptoms of the milder form of the disorder.
They found that 21% of the patient group met criteria for
obsessive-compulsive disorder. Within
this group, 37% of these patients were diagnosed with anorexia nervosa
compared to only 3% of those with comorbid OCD who had bulimia nervosa.
Through these measures they also wanted to determine whether the OCD
problems predated the eating disorder or were developed after the onset of the
eating disorder. They found that
in the majority of cases the OCD predated the eating disorder.
These results suggest that OCD is comorbid with eating disorders.
They also suggest that this relationship appears to be more strongly
related to anorexia nervosa than bulimia nervosa.
It also appears in these results that in most cases the symptoms of OCD
were present before the development of the eating disorder.
This study helps to establish a relationship between the two disorders
and provides a basis for further research to investigate the nature of this
linkage, and its particularly strong ties to anorexia nervosa.
study, by Bienvenu and colleagues (2000), investigated the relationship
between OCD and a spectrum of disorders which tend to show some similar
traits. This spectrum includes body dysmorphic disorder, anorexia,
bulimia, pathological grooming conditions, and other impulse control disorders
such as pathological gambling and kleptomania.
The study sought to determine whether OCD was related more closely to
any of the disorders in what it typically referred to as the
obsessive-compulsive spectrum or whether these disorders are each inherently
different in their own regard. This
study also sought to examine the prevalence of these disorders within
families, to try and determine whether there is an underlying biological
component between OCD and the other disorders in this spectrum. They used 80 case and 73 control subjects to analyze these
hypotheses. They also used the
data gathered from 343 case subject family members and 300 control family
members to investigate the family linkages that may be behind the disorders.
Each of the subjects as well as the family members of the subjects were
examined by psychiatrists, or psychologists using the Schedule for Affective
Disorders and Schizophrenia-Lifetime anxiety version.
Two psychiatrists then independently evaluated the diagnoses made by
the interviewing psychologists to make sure that the diagnoses were correct.
They found that 14% of the case patients who were diagnosed with OCD
also had anorexia or bulimia. They
found that 41% of the case subjects have pathological grooming conditions,
such as nail biting or nail picking. While
they did find relations between eating disorders and pathological grooming
conditions and the occurrence of OCD they failed to find this relationship
with any of the other obsessive-compulsive disorder spectrum disorders.
These finding suggest that eating disorders and OCD are indeed related.
This study also provides further evidence for the previous study’s
finding that OCD symptoms were present before the onset of an eating disorder
since the initial criterion for this study was a diagnosis of OCD. This method was also very sound due to the personal
interviewing and re-evaluation of the interviews by trained psychiatrists.
This study provides further evidence for this relationship as well as
demonstrating that the relationship is specific to eating disorder and
grooming conditions and not found in other disorders which share similar
characteristics with OCD.
these two studies demonstrate that there is a relationship between OCD and
eating disorders, they do not address what the nature of this relationship may
be. A study by Bastiani and
colleagues (1996) investigated which symptoms of OCD are most present in
eating disorders. To determine
which OCD symptoms are more prevalent than others they took a sample of 18
patients with anorexia nervosa who were being treated at an inpatient clinic
and 16 patients with OCD who were enrolled in outpatient therapy at the same
institution and had them complete the Yale-Brown Obsessive-Compulsive scale.
By examining patients that were diagnosed with these two disorders
separately and using a measure to test obsessive-compulsive tendencies they
hoped to learn how the two disorders are related. They found that patients in both groups had similar scores on
the Yale-Brown inventory, with scores ranging from 19 to 22.
While the two groups tended to have similar scores they differed on the
items of the questionnaire which they endorsed as true with relation to
themselves. Patients with OCD
tended to endorse a high number of obsessive-compulsive tendencies in a wide
range of areas from counting and checking to ordering.
They found those patients with anorexia, while they have similar
scores, tended to endorse items dealing with symmetry and order only.
These results suggest that there are particular characteristics of OCD
which are manifested in patients with eating disorders while the other facets
of the disorder may not be very relevant.
This study helps to delineate which symptoms may be important to target
in treatment and which ones may be important for the development of an eating
next set of studies examines the treatment of bulimia or anorexia in those who
are comorbid for OCD. The two
studies examine treatment outcomes relating to the symptomatology of eating
disorders as well as the symptoms related to OCD.
The first study conducted by Thiel and colleagues (1998), examines the
outcome data for patients with anorexia or bulimia and OCD at thirty months
after hospitalization for an eating disorder.
The study looked at 75 female inpatients that met criteria for bulimia
or anorexia and were patients in an inpatient treatment facility.
They looked at the patients first during the course of their inpatient
treatment and then they followed the patients thirty months after they were
discharged from the hospital. They
evaluated patients at both junctures using a diagnostic interview as well as
the Eating-Disorder Inventory and the Hanburg Obsession-Compulsion Inventory.
They found that 51% of patients at the thirty-month follow-up no longer
met criteria for anorexia or bulimia. This
improvement was not related to earlier presence of OCD.
Analysis demonstrated that significant improvement on at least 6 of the
8 Eating Disorder Inventory subscales regardless of the presence of OCD.
They also found that those who were the most recovered from their
eating disorder at follow-up showed the greatest reduction in their obsessions
and compulsions as well. This
study shows that those who receive greatest benefits from treatment also
reduce their OCD behaviors. This
study also demonstrates that the treatment of an eating disorder is in
significantly impaired by the presence of OCD.
study, which investigates OCD symptoms and treatment of eating disorders,
examines bulimia specifically. This
is a unique study, performed by Von Ranson and colleagues (1999), in that it
targets bulimia specifically, which is rare in the literature, and that the
study examines symptoms both before and after treatment.
The study examines the relationship between OCD symptoms before and
after inpatient treatment for bulimia nervosa.
This study used three cohorts, the first consisted of 31 patients who
were currently being treated for bulimia, the second consisted of 29 women who
had been recovered from bulimia nervosa for more than 1 year, and the third
group was a control group of 19 comparison females.
All subjects completed the Yale-Brown Obsessive-Compulsive scale, which
measures OCD symptoms and the items specifically dealing with core eating
disorders were eliminated from the inventory before it was distributed to the
subjects. The results showed that
both patient groups had significantly higher scores of the Inventory than did
the control subjects. The current
bulimics scored around 13, the recovered bulimics scored around 7.9 and the
control subjects showed scores of around 1.9.
Within the patient groups there was a marked difference in those who
had undergone successful treatment to those who are currently undergoing
treatment. Even though the groups
differed in terms of severity of behavior they recovered as well as current
bulimics tended to endorse symptoms dealing with symmetry and exactness.
This study provides evidence that bulimics have symptoms of OCD as well
as anorexics, which is the relationship that most literature focuses on.
It also demonstrates that OCD symptoms targeted in treatment such as
exactness and symmetry are significantly improved in-patients who have
recovered from bulimia.
studies presented in this paper are indicative of the work that is being done
investigating the relationship between OCD and the eating disorders. The first two papers were good examples of the relationship
that is found between patients either with an eating disorder that also have
OCD or those with OCD who also have an eating disorder. The second group of studies examined this relationship
further to try and delineate which symptoms if any are more indicative of OCD
in those patients who also have an eating disorder.
In the last group of studies the researchers built on the literature
presented in the first paper and investigated the relationship in terms of
treatment implications. It
appears that there is a strong link between OCD and eating disorders,
especially OCD symptoms dealing with order, symmetry and exactness. It is also evident that these symptoms diminish with
successful treatment of an eating disorder.
these studies provide evidence of the relationship between OCD and eating
disorders, they also fail to target the possible nature of this relationship
in terms of biological ties. There
is currently some new work being done investigating the role of serotonin in
both OCD and eating disorders as this possible biological link.
These studies also all examine patients who are in inpatient treatment
facilities. These cases may be
the most extreme cases of eating disorders and may present a biased sample who
may be more at risk to develop OCD symptoms in the first place.
Despite these methodological flaws it seems clear that a relationship
exists between OCD and eating disorders.
This research has provided a base for more exploration into the
biological nature of the relationship, possible treatment modalities, which
include treating symptoms of OCD and the evaluation of OCD symptoms as an
important part in learning the true cause of an eating disorder.
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Rubenstein, C., Weltzin, T. E., & Kaye, W.
(1996). Comparison of Obsessions
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Hoehn-Saric, R., Liang, K. Y., Cullen, B.
M., Grados, M. A.,
& Nestaldt, G. (2000). The relationship of obsessive-compulsive disorder
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