Eating disorders, such as anorexia nervosa, bulimia nervosa, and binge eating disorder, have been hypothesized to have a relationship with obsessive-compulsive disorder. However, there remains a great amount of evidence in favor that anorexia nervosa and obsessive-compulsive disorder share more similarities than bulimia nervosa or binge eating disorder. The implications of integrating eating disorders with obsessive-compulsive disorder to create a "family" of disorders called obsessive compulsive spectrum disorder will be discussed. There remain some differences between eating disorders and obsessive compulsive disorders which further explore the correlation. Furthermore, review papers and primary research papers support that a correlation exists between eating disorders and obsessive compulsive disorders, and the research acknowledges the differences between the two disorders. However, two primary research papers do not believe that there exists a correlation between the two disorders. In all, the implications of the relationship between the two diseases, the treatment of the two diseases, and suggestions for further and diverse research will be explored
The DSM-IV definition of anorexia nervosa has four conditions. The definition
states: "I) Refusal to maintain body weight for age and height; 2)
intense fear of gaining weight or becoming fat, even though underweight;
3) disturbance in the way in one's body weight, size, or shape is experienced,
undue influence of body weight or shape on self-evaluation, or denial of
the seriousness of the current low body weight; and 4) in females, ammenorrhea"
(1). There remain two kinds of an nervosa as well the
restricting ": "the person has not regularly engaged in binge-eating
or purging behavior-" and the binge-eating/purging type.-
"in which the person has regularly engaged in these behaviors"
(1). Anorexia nervosa usually occurs during adolescence and in females.
This definition becomes important in understanding the relationship
between anorexia nervosa and obsessivecompulsive disorder.
The DSM-IV definition of obsessive-compulsive disorder states:
"an anxiety disorder, where it is defined as obsessions
and/or compulsions that cause marked distress, are time-consuming,
or interfere with functioning. Obsessions are defined as recurrent
and persistent thoughts, impulses or images that are experienced
as invasiive and ego-dystonic and that cause anxiety or distress. Compulsions
are defined as ritualistic behaviors or mental acts that the person
feels driven to perform in response to an obsession or according to rules
that must be rigidly applied. The behavior or mental act is
aimed at preventing or reducing distress or preventing some dreaded event
or situation and is recognized as excessive or unreasonable"
(1). ObsessiveCompulsive disorder begins in late adolescence and has
a prevalence rate of 1.9% to 2.8%, (1).
Two review papers, conducted by McElroy et. al (1994) and Jarzy and
Vaccarino (1996), state that a relationship exists between obsessive compulsive
disorder and anorexia nervosa because the definition of the two disorders
share many phenomenological similarities (1,2). However, the McElroy review
paper contains extensive information and suggests that there remains a
sufficient amount of evidence which advocates the integrating of these
diseases into a "family of OCD spectrum disorders." The researchers
state that the fears and obsessions of people with anorexia nervosa prove
to be similar to the obsessions that people with OCD experience. The review
paper further believes that because anorexics excessively diet, over-exercise,
evaluate themselves in the mirror, and have "food-related rituals,"
they share the compulsions of people with OCD. One study tested hospitalized
anorexic patients and proved that 50% of these patients could be defined
as having obsessive-compulsive disorder (Solyom et. al). Another study
proved that obsessive-compulsive symptoms remained the second most recurrent
symptom of anorexia nervosa (Rothenberg). Importantly, OCD and anorexia
nervosa both occur during adolescence. In addition, high rates of anorexia
nervosa occur m women who have OCD. One study stated that 11% of women
with OCD experienced a past history of anorexia nervosa (Kasvikis et al.).
Tamburrino et al. reported that 42% of OCD females had a history of anorexia
nervosa. Further studies also propose that people with anorexia nervosa
and OCD share family history and biological abnormalities. OCD and anorexia
nervosa have some differences, especially concerning gender. Females constitute
a larger percentage of anorexia nervosa than females with OCD. In addition,
anorexia nervosa contains more ego-syntonic symptoms, thus therapy between
the two disorders might have to be distributed differently. A possible
family of OCD spectrum disorders could produce many benefits. One benefit
is that recognition of the related disorders could become established because
of the realization of high comorbidity. As well, if compulsive and impulsive
features were explored, then psychopharmacological and physiological treatments
could be more productive and effective. In all the review paper believes
that anorexia nervosa and OCD should be broadened to a definition of OCD
spectrum disorder because there remains strong support that a relationship
exists between the two disorders (1).
An additional review paper by Hsu Kaye, and Weltzin (1993) supports
that a relationship exists between anorexia nervosa and OCD because there
remains similarities in the studies of phenomenology, comorbidity, neurotransmitters,
and central nervous system functional metabolism. The researchers suggest
that many studies prove that 20 to 30% of patients with anorexia nervosa
have obsessive-compulsive traits. The Leyton Obsessional Inventory test
conducted by Smart, Beumont, and George provided evidence that patients
with anorexia nervosa have high levels of four scales: symptom, trait,
resistance, and interference. On the other hand, some studies (Kasvikis,
et. al) found that 10.5% of OCD patients had a history of anorexia nervosa.
In the review paper, other studies contain similar findings. The researchers
concluded that people with anorexia nervosa have shared OCD symptoms, which
place them into the diagnosis of OCD. Patients with OCD also have severe
eating disorder symptoms. The researchers also believed that neurobiological
findings suggest that people with anorexia nervosa and OCD could both have
a disturbed serotonergic functioning. Although the researchers remain positive
about the correlation, they believe that it remains difficult to make absolute
conclusions because of the difficulties in understanding the etiology of
the two disorders (3). Thus, the culmination of these three review papers
believe that a relationship between anorexia nervosa and OCD exists because
the studies that they encountered prove this correlation.
Fahy, Osacar, and Marks (1993) tested 105 female patients who have
OCD to find out if they had a history of anorexia nervosa. The researchers
conducted this study because they believed that the phenomenology of the
disorders overlap. They found that 11% of their OCD female patients had
a history of anorexia nervosa. This study also mirrors a study conducted
in 1986 by Kasvikis et al. Thus, they concluded that the two disorders,
among females, share similar traits (4).
Another primary research report conducted by O'Rourke, Wurtman, Tsay, Gleason, Baer, and Jenike (1994), studied the differences between 170 patients with OCD and 920 controls regarding eating and snacking patterns. 10% of the female patients had a ]history of anorexia nervosa or buhnna nervosa, compared to 2% of the control group. Thus, the researchers believed that this statistic provides evidence that a con-elation exists between patients who have OCD and a history of an eating disorder (5).
Two other primary research reports found that a relationship exists between patients with OCD and patients with anorexia nervosa. Castle, Deale and Marks (1995) found that females with OCD had a history of an eating disorder, more males with OCD. Studying 219 patients gave them the evidence to support that there is a high prevalence of a past history of anorexia nervosa in OCD female patients. The researchers also suggested that the gender difference of people with OCD and anorexia nervosa should be recognized (6). One primary research report by lancu Kikenzon, Ratzoni, and Apter (1993) studied a 16-year-old who had anorexia nervosa and who had also acquired obsessive-compulsive disorder. They believed that a clinical link remained between anorexia nervosa and obsessive-compulsive disorder (7). In summary, these primary research reports provide concrete evidence which reiterate the importance in comprehending the relationship between OCD and anorexia nervosa.
Black, Goldstein, Noyes, and Blum (1994) do not support the relationship between anorexia nervosa and OCD because they believe that superficial similarities exist They believe that improper term describe the relationship because numerous behaviors are "compulsive." They acknowledge that OCD is prevalent in patients with anorexia nervosa and vice versa. But they propose that no evidence remains that eating disorders occur in OCD as a "natural complication-" They firmly believe that family studies should be an important aspect in discerning people with CCD. Thus, the researchers studied 32 subjects with OCD, 33 controls, and their respective first-degree relatives. These studies have not shown to prove a relationship among OCD and eating disorders. In all the researchers were unable to find a family relationship between eating disorders and OCD. They believe that there remains no convincing evidence, as of yet, to allow the two disorders to become linked (8).
A group of researchers, Sunday, and Einhom (1995), conducted a study of 100 anorectic and bulimic patients using the Yale-Brown-Cornell Eating Disorder Scale to discern if these patients had obsessive compulsive characteristics. Forty-seven of the eating disordered patients had anorexia nervosa and the anorexics had high levels of severe preoccupations. However, they believed that these preoccupations were ego-syntonic, and this remains an important difference from the ego-dystonic traits inobsessive compulsive disordered patients. This research confirms that patients with anorexia nervosa have severe preoccupations and that some traits do co-exist, however it does not state that an concrete relationship exists between anorexia nervosa and OCD. Thus, purpose of the report was to explore the similar traits between the two disorders and the researchers avoided absolute conclusions (9).
VII. Suggested Treatment and Future Direction For the Correlation of Anorexia Nervosa and Obsessive-Compulsive Disorder.
Phillips, Kim, and Hudson (1995) believed that anorexia nervosa contain have a subtype about obsessions, with a "implied continuum" when defining the disorder. Thus, this subtype may make a more useful classification and help treatment approaches (10). Allison (1993) strongly stated that the selection of control groups needs to become more rigid and accurate when studying OCD and its relationship to eating disorders. The researcher believed that descriptive studies are inadequate and many restrictions should be placed on the selection of control groups to produce more precise evidence (11). More effective treatment needs to be explored as in a previous study conducted by Hsu et al., 50% of the patients with anorexia nervosa and OCD recovered. One study strongly suggests that large family studies should be researched when comparing OCD and anorexia nervosa (8).
The methods of treatment remain integral in understanding the correlation because effective treatment for both of the disorders further strengthens the hypothesized relationship between OCD and anorexia nervosa. Bradley and Kulik (1993)discussed the importance of fluoxetine m treating the two disorders, regarding its side effects, They believed that many problems remain in administering this drug because it effects memory impairment. They came to this conclusion through studying a student with anorexia nervosa and OCD who had been 60 mg. of fluoxetine and had difficulties in memory retention. Her memory was restored through a lower dosage of 20 mg. of fluoxetine (12). Strakowsky McElroy, Keck and West (1994) stated that further treatment should assess co-occurrence between the two disorders in order to aid the treatment of patients which would help to alleviate medical costs (13). One primary research report, McElroy and Keck (1995), supports treatment of these two disorders through conventional psychopharmacological agents (14). McElroy et al. and Hsu et al. believe that data proves that OCD and anorexia nervosa may be delineated through serotonergic reuptake inhibitors (1,3). Hsu et al. mentions a study in which fluoxetine was given to anorectic patients with OCD and this medication helped restore 83% of the anorectics body weight (3). Fahy et al. suggested that OCD symptoms in patients with anorexia nervosa should be accurately assessed so that a combination of behavioral, cognitive, and pharmacological treatments can become completed (4). In summary, the majority of the studies believed that both disorders must be carefully estimated in order to have effective treatment and they suggest the SRIs produce positive outcomes in patients with OCD and anorexia nervosa.
The review papers and primary research papers suggest a strong relationship between OCD and anorexia nervosa because of phenomenological similarities and the beneficial outcomes of using one treatment (SRIS) for two disorders. Many researchers are in favor of broadening the definition of OCD into a OCD spectrum disorder. There remains statistical evidence which proves that OCD and. anorexia nervosa coexist, however these numbers vary and there remains problems concerning comorbidity and the differences between ego-systonic and ego-dystonic characteristics. In summary, further research needs to repeatedly prove that this correlation exists because there remains concrete evidence that anorexia nervosa and obsessive-compulsive disorder share numerous symptoms.
(1) McElroy SL, Phillips KA, and Keck PE Jr. (1994). Obsessive
compulsive spectrum disorder. Journal of clinical Psychiatry, 55, 33-53.
(2) Jarry JL. and Vaccarino Fj. (1996). Eating disorders and obsessive
compulsive disorder: neurochemical and phenomenological commonalities.
Journal of Psychiatry and Neuroscience, 21(l), 36-48.
(3) Hsu LK., Kaye W., and Weltsin. (1993). Are the eating disorders
related to obsessive compulsive disorder? International Journal Of
Eating Disorders, 14(4), 305-318.
(4) Fahy TA., Osacar A, and Marks 1. (1993). History of eating
disorders in female patients with obsessive-compulsive disorder. International
Journal Of Eating Disorders, 14 439-443
(5) O'Rourke DA., Wurtman J.J., Wurtman RJ., Tsay R., Gleason
R., Baer L., and Jenike MA. (1994). Aberrant patterns and eating disorders
in patients with obsessive compulsive disorder. Journal of Clinical Psychiatry,
55, 445-447.
(6) Castle DJ., Deale A., and Marks IM. (1995). Gender differences
in obsessive compulsive disorder. Australian and New Zealand
Journal Of Psychiatry 29(l),114-117.
(7) Iancu I, Kikenzon L, Ratzoni G, and Apter A. (1993). Anorexia
nervosa and obsessive-compulsive disorder in a young Russian immigrant.
Harefuah, 124,, 477-479.
(8) Black DW., Goldstein RB., Noyes R Jr., and Blum N. (1994).
Compulsive behaviors and obsessive compulsive disorder (OCD): lack of a
relationship between OCD, eating disorders, and gambling Comprehensive
Psychiatry, 35(2),145-148.
(9) Sunday SR., Halmi, KA, and Einhom A. (1995). The Yale-Brown-Cornell
Eating Disorder Scale.- A new scale to assess eating disorder symptomatology
International Journal of Eating Disorders 18(3), 237245.
(10) Phillips KA, Kim JNL, and Hudson JI. (1995). Body image disturbance
in body dysmorphic disorder and eating disorders. Obsessions or delusions?
Psychiatric Clinics of North America, 18, 317-334.
(11) Allison DB. (1993). A note on the selection of control groups
and control variables in comorbidity research. Comprehensive Psychiatry
21(5), 336-339.
(12) Bradley SJ. and Kuhk L. (1993). Fluesetine and memory impairment.
Journal of the American Academy of Child and Adolescent Psychiatry,
32(5), 1078-1079.
(13) Strakowski SM., MeElroy SL., Keck PW Jr., and West SA. (1994).
The co- occurrence of mania with medical and other psychiatric disorders.
International Journal of Psychiatry in Medicine (4), 305-328.
(14) McElroy SL. and Keck PE. (1995). Misattribution of eating
and obsessive- compulsive disorder symptoms to repressed memories of childhood
sexual or physical abuse. Biological Psychiatry, 27(l), 48-51.
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