OCD and eating behaviors
Most folks who aren’t mental health providers may not realize how separate various factions of the mental health community are. Behaviorists tend to hang out with other behaviorists. IFS folks gravitate towards other IFS folks. Adult therapists sometimes don’t know many child therapists. And EATING DISORDER therapists are magical to me. I cross paths with them in my Radically Open DBT work (RO) because RO tends to work well for over-controlled eating behavior. To be calm and centered in the face of the potentially high medical risk that can accompany eating disorders is amazing. So when a fellow therapist asked me about the intersection of OCD and eating disorders, my first impulse was to respond “No no…. I don’t know anything about eating disorders. I’m just an OCD therapist.”
But then I realized, OCD intersects with eating issues all the time and while I’m not an eating disorders specialist, I do know things about restrictive eating. I’m not going to pretend to know everything about other eating disorders but what I can say is that the eating behavior differences I see in OCD is almost always actually Illness Anxiety Disorder, formerly known as hypochondriasis, or sometimes called health anxiety.
If we look at the regular ole OCD cycle, it can begin in any of these three areas: Involuntary experiences, environmental triggers, or behaviors (visible or private) and gets worse with more engagement/trying to fix it. Most sufferers of IAD are highly sensitive to sensations in the body and ascribe meaning to this sensations. They then may change eating behavior in an effort to reduce sensations. The effort to reduce sensations leads to sensitization to sensations, which leads to noticing more sensations, and the cycle intensifies.
Personal story of IAD
I’m going to use a personal story here. Back when I was in junior high, I went through a period of what I’d certainly call IAD if I was diagnosing myself today. I come from a long line of anxious people and 13-14 years old is a high risk time for the development of OCD behavior, so it’s not surprising that I would have gone through a period of IAD. I had a GI infection that resulted in awful diarrhea for several weeks (being an OCD therapist involves a lot of talk about bodily fluids so brace yourself as you read my blogs). As a 14 year old, it’s tough to return to school when you’ve been pooping 10x a day for weeks. My gut was recovering from whatever happened with that GI illness and I still had plenty of motility weirdness, gas, and gut sensations. Even as symptoms got better from the medical perspective, I persisted in worrying that something was wrong with my gut. So I ate a lot of… Golden Grahams. Golden Grahams cereal became my safe food and it became one of the few foods I would eat for awhile. I then added red grapes to the rotation. I remember Garden Burgers with mustard was the next thing I added in. It was a good two years of really restricted eating and a lot of Mylanta before I returned to something that resembled a normal diet.
If we break this down into “OCD cycle pieces,” I was always so aware of my gut sensations (involuntary experiences). When I knew I couldn’t access a bathroom, I’d get extra nervous, which would make my gut sensations more intense (environmental trigger speeding up sensations). Then I would restrict food and worry about what was wrong with my GI tract (overt and covert behaviors). The sensations made the worry and restriction worse. The worry made the sensations and restriction worse. The restriction made the sensations and worry worse. It was an awful cycle. I gradually added foods back in, probably because I am highly food-motivated, like a Labrador Retriever. I recovered without a formal intervention but in retrospect, this was classic IAD/OCD.
Clients who have food-related OCD/IAD tend to be fearful that food could be the source of a health problem: Allergies, food borne illnesses, contamination with chemicals, carcinogens, intolerances, etc. They monitor sensations in their bodies for evidence of their body reacting to foods and since if we tune into sensations, we can always find them, there’s always evidence that we’re reacting in SOME way to foods. This cycle can result in a very narrow diet and difficulty reintroducing foods. Luckily, this cluster of symptoms responds really well to ACT-informed ERP. It’s also REALLY fun to work with clients on finding delicious and creative ways to expand their food intake because I like to cook. As long as their medical team has ruled out actually medical issues related to food, they’re not relying on me for nutritional expertise. For more on IAD, check out my discussion with Jeff Guenther on the Therapy Den podcast.