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Anorexia Nervosa is an eating disorder often found in young adolescent women, that has been characterized by a distorted attitude towards weight and body image, a set of behaviors calculated to produce weight loss and other physiological and psychological symptoms. Physiological symptoms include (according to the DSM III- R criteria) starvation, amenorrhoea, and a refusal to maintain weight above 85% of their ideal weight. Psychological symptoms include an obsessive pursuit of thinness, along with obvious body preoccupation, and an incessant rumination about food. In addition, they are also engaged in compulsive calorie counting and excessive physical exercise. The personality of the anorexic is characterized as stereotypically rigid, ritualistic, perfectionistic and meticulous. This ritualism takes its form in eating patterns. For example an anorexic may cut her food into tiny pieces and weigh every piece of food before she eats it. These behaviors can be found in people who are on a normal, healthy diet, but in anorexics these behaviors are extremely exaggerated, in part because the act of dieting has become exaggerated. Anorexics also commonly have obsessions and compulsions related to symmetry and order.
Obsessive-compulsive disorder (OCD), one of the anxiety disorders, is a potentially disabling condition that can persist throughout a person's life. Those who suffer from OCD become trapped in a pattern of repetitive thoughts and behaviors that are senseless and distressing. Some of the main components of OCD are obsessions, compulsions and insight into behavior. Obsessions are unwanted ideas or impulses that repeatedly well up in the mind of the person with OCD. Persistent fears that harm may come or an excessive need to do things correctly or perfectly, are common. In response to their obsessions, most people with OCD resort to repetitive behaviors called compulsions. The most common of these are washing and checking. Other compulsive behaviors include counting, repeating, hoarding, and endlessly rearranging objects in an effort to keep them in precise alignment with each other. Some people with OCD have regimented rituals while others have rituals that are complex and changing. Performing rituals may give the person with OCD some relief from anxiety, but it is only temporary. People with OCD usually have considerable insight into their own problems. Most of the time, they know that their obsessive thoughts are senseless or exaggerated, and that their compulsive behaviors are not really necessary. However, this knowledge is not sufficient to enable them to stop obsessing or carrying out the rituals.
After reading the description of Anorexia and OCD, one can identify many similar symptoms among the two disorders. In addition to these common symptoms, there are biological similarities as well, since serotonin dysfunction has been implicated as one of the possible causes of OCD and anorexia (as well as bulimia nervosa). These factors have led many investigators to study the relationship between anorexia and OCD. Most systematic and controlled studies using a large sample have concluded that there is an association between the two disorders. Various investigators found that OCD was more common in anorexic patients that in the general population, and anorexia was more common in patients with OCD than in the general population. However, the nature of this relationship is still controversial, and this is the question that I attempt to address in this literature review: Is Anorexia Nervosa a manifestation of Obsessive Compulsive Disorder or is Anorexia a separate illness often comorbid with OCD?
Anorexia as a Manifestation of OCD
One of the biggest proponents of anorexia as a manifestation of OCD is Albert Rothenberg. He believes that social and educational factors, along with a predisposition to obsessive compulsive illness influence the development of anorexia, and social and educational factors also contribute the development of OCD. He further states that recently, obsessive compulsive neurosis has emerged among adolescent girls in a form involving food and disorders of eating. In Western culture, anorexia nervosa and bulimia have become a predominant form of obsessive compulsive illness. According to Rothenberg, anorexia is a modern manifestation of OCD, because thinness in women has become a major and pervasive criterion for attractiveness and beauty. Thinness in women is crucial in order to look good in clothing, and the prescribed female look is that of a fashion model with no breasts, a completely flat abdomen, with slim hips and no butt. The ideal figure of a rounded female has been replaced by the new ideal, sleek and slim. Tyrannically imposed in these societies by the constant surveillance and competition of women and supported by the passive acquiescence of men, this cultural ideal has played a role in producing the symptoms of the obsessive- compulsive food disorders (Rothenberg, 1990).
Rothenberg’s theory of anorexia as a manifestation of OCD is broken down into the obsessional concern with food and a focus on control. The preoccupation of food found in anorexics depicts the intrinsic obsessive nature of the eating disorder. Anorexics consciously and deliberately refuse food. The lack of perceptional cues related to hunger as described by Hilda Bruch appear later on in the course of the illness, but in the early stages there is the constant awareness of mild to strong feelings of hunger. In addition to this hunger, there is a persistent preoccupation with food in a concrete way in the form of ruminative calorie counting and mental imaging of food. Because these individuals consciously and persistently pursue thinness, it appears that they are voluntarily attempting to obtain a goal. However, as with classic obsessive compulsive symptomatology involving hand washing and ruminative ideas, the preoccupation is far excessive to the goal. It involves involuntary rumination on caloric numbers and on food, and it is experienced as dystonic and out of the individuals control by the patients themselves (Rothenberg, 1990).
Along with an obsession with food there is also a focus on control. Preoccupation with control is pervasive in the lives, personality and symptomatology of persons with eating disorders. Directly involved in the relentless pursuit of thinness are control of weight, control of appetite, control of thoughts, and ritualistic control of the environment. For this reason, amenorrhea among anorexics may represent a successful control of bodily functions. The patients themselves are aware of their own concern about control and often rationalize their eating disorder by saying that they control what they eat and take in because they cannot control anything else in their life. However, this control seems a bit ironic because anorexics often lose the mastery of control because they are so obsessed with the idea of control. They don’t seem to realize that the strict control of diet and bodily functions does not lead them to success but to a state of physical impairment and weakness, and eventual hospitalization, where they must eventually relinquish their control over their body to the physician. This focus on control is not unique to those with anorexia, it is core factor in OCD. Obsessional ideation functions to gain control over impulses, wishes, and affects. Compulsive rituals function as attempts to gain control over the same types of factors in action (Rothenberg, 1990).
Aside from obsessional concern with food and a focus
on control there are other similarities between OCD and anorexia, often
found in character structure, or personality traits. Typical behavior
patterns include, perfectionism, excessive orderliness and cleanliness,
meticulous attention to detail, stubbornness and rigidity. Other
less specific features of OCD are negativism, rebelliousness, and intense
dedication to physical activity. The negativism is the prominent
principle displayed in the refusal to eat and in the resistance to all
positive efforts by other to reinstate a healthy diet. The high level
of physical activity and drive to exercise, requiring high degrees of energy
in the face of severe weakness and thinness, results from the compulsive
drive to succeed, and attain ones goal, in this case weight loss (Rothenberg,
Rothenberg tested his theory of anorexia as a manifestation of OCD in a study at a long-term, fully open psychiatric hospital. The primary measure of behavior of the patients was the patients own therapist. The measurement was based on psychotherapy four times a week. In order to evaluate the connections between obsessive compulsive features and the eating disorders, patients with eating disorders (ED) were compared with a randomly selected group of hospitalized patients with a wide variety of other types of primary psychiatric disorders. The ED sample consisted of 12 hospitalized patients (all females) who met the DSM- III- R criteria for anorexia nervosa and bulimia nervosa. The non eating disordered group (NED) consisted of 12 patients selected at random form the NED remainder of the hospital population. The NED group consisted of 6 males and 6 females, because according to epidemiology, OCD symptomatology is at least as common as in males and females, so males were included in the study to prevent skewing due to gender factors. There were no significant differences in the age of the patients or the length of observation an hospital treatment. In order to determine overall diagnosis, the presence or absence of eating disorder, and to assess concomitant behavioral manifestations of OCD, patients’ highly detailed records and the case abstracts were studied carefully and the patients individual therapists were polled in writing.
The results indicated that the groups differed significantly on every one of the eating disorder symptoms (intense fear of becoming obese, disturbance of body image, weight loss of at least 15% of normal body weight, refusal to maintain normal body weight, binge -eating, self induced vomiting, laxative and diuretic abuse, and amenorrhea), except for psychologic illness producing eating disorder pathology. The classic obsessive- compulsive behavioral manifestations of cleanliness, orderliness, perfectionism, rigidity and excessive fear of change, miserliness, and scrupulousness were all significantly associated with the ED group. In addition, obsessive manifestations of mental rumination involving food rituals were significantly associated with the ED group. Although based on a relatively small sample of patients, these results are derived from long-term detailed observation and suggest a definite association between an obsessive compulsive picture and eating disorders (Rothenberg, 1990).
Anorexia and OCD as Comorbid Illnesses
On the flip side of the coin, many investigators have found the relationship of anorexia and OCD to be one of common symptoms but different illnesses. It has been refuted that anorexia is not a manifestation of OCD because, although obsessional traits and symptoms are a prominent feature of anorexia, the role of severe starvation and weight loss in the genesis of these traits has been emphasized, and the possibility of these obsessional traits and symptoms have been considered as a secondary phenomena to starvation (Garfinkel and Garner, 1982). It has also been discussed as to whether OCD- like symptoms related to core anorexia pathology fully meet the criteria of OCD. Most patients with anorexia do not regard their obsessive- like symptoms including, recurrent, persistent and intrusive thoughts about their body image and desire for thinness as senseless, and often they do not attempt to ignore or suppress these thoughts. Anorexic patients with obsessive symptoms are also suggested to be different from those with OCD in that their compulsion- like behaviors, such as persistent exercising and ritualized eating, might not be designed to neutralize or prevent discomfort (Matsunaga et al, 1999).
On the other hand, some studies on the axis I co-
morbidity have suggested that 11-69% of anorexic patients have a current
or lifetime OCD, even after excluding food and body related obsession-
like symptoms or ritualized eating behavior. In addition, studies
on OCD have suggested about 10% of female patients with OCD had a history
of anorexia (Fahy et al, 1993). These studies indicate a close relationship
between OCD and anorexia, and suggest that considerable numbers of patients
with anorexia have OCD symptoms severe enough to qualify for a diagnosis
In a study conducted in Japan (Matsunanga et al, 1999), the group assessed the prevalence of comorbidity of OCD among Japanese patients with anorexia, distinguishing anorexic patients with OCD (AN +OCD) from those patients without OCD (AN- OCD); and evaluated the characteristics of OCD symptomatology using the Yale- Brown Obsessive- Compulsive Scale (Y-BOCS) in AN+OCD in comparison with patients who had OCD (pt + OCD).
The results show that 40% of the anorexic patients met the criteria for concurrent OCD, even after excluding the core obsessional symptoms typical of anorexia. However, this study does not state what the prevalence of OCD is in the general population (of Japan), so it is not known if this number is significant, especially if the prevalence of OCD in Japan is very high. Also, AN patients had similar functional impairment from primary OCD symptoms as indicated by their Y-BOCS to that of OCD patients. These findings support the results, suggesting that patients with active AN often manifest significant impairment from primary obsessive or compulsive symptoms with similar magnitude in severity to that of OCD. In the AN +OCD group, symmetry and ordering is the most common dimension of OCD, followed by, cleanliness and washing. On the other hand in the pt +OCD group, a wider variety of symptoms was observed (aggressive, somatic, sexual, and religious compulsions) in addition to those found in the AN +OCD group. Another important finding in this study has do with the association of Obsessive Compulsive Personality Disorder and Anorexia Nervosa and OCD. A close linkage between OCD and OCPD in AN patients may represent a causal significance of OCPD on their OCD symptoms.
In another study (Bastiani et al,1996), the group found similar results to the Matsunaga study. This group found that patients with anorexia and patients with OCD had similar scores on the Yale -Brown Obsessive- Compulsive Scale. This suggests that these disorders have a similar magnitude of impairment from obsessions and compulsions. The OCD patients had a greater quantity and variety of OCD target symptoms than did anorexics, including, sexual, aggressive, and contamination obsessions. Anorexics had symptoms pertaining to symmetry, exactness, ordering, and arranging. Anorexics had particular concerns with ordering and cleanliness, or obsessions with perfectionism or things going wrong. This study also refutes the idea of anorexia as a manifestation of OCD. They believe that there are reasons to think that the two disorders are different illnesses that may share certain common symptoms. First, OCD symptoms, as well as core eating disorder symptoms, tend to be ego syntonic in anorexics. In contrast, ego- dystonic symptoms are more commonly, but not always, found in OCD patients. Second, mood and behavioral responses after administration of the drug m- CPP, a serotonin specific agent, are opposite in character for patients with anorexia and OCD. The drug tends to improve the mood in anorexics, while it makes most OCD patients more obsessional and anxious. Third, while a substantial proportion of anorexic patients have a lifetime diagnosis of OCD, not all anorexic patients warrant this diagnosis. Thus there may be a limited overlap between anorexia and OCD (Bastiani et al, 1996).
Another study (Zubieta at al, 1995) attempted to asses the comorbidity of OCD and Anorexia in the severity of the eating disorder. The primary objective of the study was to examine the association between the severity of their obsessive compulsive features and the symptoms of eating disorder itself. The study found that the presence of higher obsessionality scores seemed to identify more severely disturbed attitudes about eating, dieting and body image, among the eating disordered group. The individuals with higher obsessionality scores also scored higher in the Obsessional Symptoms Checklist, the Eating Disorder Inventory and the Beck depression inventory; these patients also showed higher numbers of psychiatric hospitalization. In addition, elevated obsessional- compulsive scores obtained after a two year follow up were associated with the presence of lower body weight and more severe eating disorder symptoms at that time. These results support the hypothesis that elevated obsessionality is associated with more severe eating disorder symptomatology.
In summary, a close relationship between Anorexia Nervosa and Obsessive- Compulsive Disorder has been established, however it is the nature of this relationship that remains controversial. The two types of relationship proposed are anorexia as a manifestation of OCD and anorexia and OCD as comorbid illnesses. The former theory is supported by Rothenberg, who calls anorexia "the modern obsessive compulsive syndrome", which has stemmed from our society’s changing attitudes about weight and thinness. According to this theory, anorexia is a manifestation of OCD because both disorders present many of the same clinical characteristics as well as similar personality traits. In anorexia there is a obsessional concern with food, which is derived from their drive to be thin, and involves involuntary rumination on caloric numbers of food. Anorexics also have a focus on control; through the eating disorder and consequences of the eating disorder they attempt to control their food intake and their bodily functions (amenorrhea). Personality traits between the two disorders are also similar, such as perfectionism, meticulousness, rigidity, and stubbornness. Rothenberg maintains the idea that there appears to be a modern form of obsessive compulsive illness beginning during the adolescent period.
However, the relationship between anorexia and OCD is also viewed as two distinct diseases with common symptoms Anorexics are usually ego- syntonic and posses obsessive - compulsive symptoms that are related to symmetry and order, whereas OCD patients have a broader range of symptoms, including aggressive, sexual, and somatic obsessions and compulsions. Anorexia and OCD are also thought to be different diseases because the use of a serotonin specific drug (both disorders are thought to be involved in serotonin dysfunction) causes opposite reaction in anorexic and OCD patients. Furthermore, not all OCD diagnoses for anorexics are warranted. These reasons suggests that phenomenological and symptomological differences exist between anorexia nervosa and OCD. Other interesting relationships between concomitant OCD and Anorexia is that higher obsessionality can result in more severe eating disorder symptomatology. Also, there is an association with Obsessive Compulsive Personality Disorder between anorexia and OCD, where the presence of obsessional personality disorder may influence the development of OCD in anorexic individuals.
Though both points of view have valid points, it seems as though the latter relationship, of anorexia and OCD as comorbid illnesses, is the more accepted point of view. However, further studies need to be done on both sides to determine if there is an unequivocal relationship between the two. Though, it very well may be true that the interaction of these two disorders is much too complex to be simplified into one of the two discussed relationships.
Bastiani AM, Altemus M, Pigott TA, Rubenstein C, Weltzin, TE, Kaye, WH (1996): Comparison of Obsessions and Compulsions in Patients with Anorexia Nervosa and Obsessive Compulsive Disorder. Biological Psychiatry 39:966-969.
Fahy, TA, Osacar, A, Marks, I (1993): History of Eating Disorders in female patients with Obsessive Compulsive Disorder. International Journal of Eating Disorders 14: 439-443.
Garfinkel, PE and Garner DM, (1982): Anorexia Nervosa: A Multidimensional Perspective. Brunner Mazel: New York.
Matsunaga, H, Kiriike, N, Iwasaki, Y, Miyata, A, Yamagami, S, Kaye, WH (1999): Clinical Characteristics in patients with anorexia nervosa and obsessive compulsive disorder. Psychological Medicine 29: 407-414.
Rothenberg, A (1990): Adolescence and Eating Disorder: The Obsessive Compulsive Syndrome. Psychiatric Clinics of North America 13: 469-487.
Zubieta, JK, Demitrack, MA, Fenick, A, Krahn, DD (1995): Obsessionality
in Eating Disorder Patients: Relationship to Clinical Presentation and
Two- Year Outcome. Journal of Psychiatric Research 29: 333-342.
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