Eating disorders and anxiety
In this article, I want to explore the links between Eating Disorders and anxiety , and then go on to look at ways of managing anxiety in a follow-up post.
Anxiety can be crippling: it certainly was for me when I was struggling with anorexia.It's weird, because I was so resilient and fearless before secondary school, and certainly before my eating disorder, but I can't really remember which came first , anorexia or anxiety, and I have definitely never known whether one made me more likely to have the other
What is anxiety?
Most people have experienced anxiety in some form or another; the sweating palms as you are invited into the interview room for the job you really need; the racing heart as you begin to say your marriage vows, or the jelly-like feeling in your legs and flash of adrenaline as you stand up to speak in public. All of these (and so many more) situations trigger stress responses in us that naturally create anxiety. For most people, after the new or potentially risky situation has passed, the feelings of anxiety naturally and easily dissipate.
When feelings of anxiety linger and cause us problems in many, if not most, life situations, you may have an anxiety disorder. Even if there isn't an immediate, objectively observable threat, those of us who struggle with anxiety are often creating anxiety by ruminating over awful possibilities, (which we're certain are soon to occur), while at the same time working out how to avoid the dreaded events.
Anxiety can have a huge impact on your life. It can account for impairment in your social and family life, educational and career development, not to mention the difficulty in even feeling a sense of joy, contentment and peace in life.
The day-to-day physical symptoms of anxiety can include breathlessness, palpitations, restlessness, muscular tension, tightness in the chest, feeling you're choking, giddiness, trembling and flushing, all of which are produced by the action of the autonomic nervous system, especially the sympathetic part of it.
Mostly, though, those of us who have struggled with anxiety know and hate that miserable, tense feeling of dread, the feeling that something is imminently wrong and something bad is about to happen.
There is a significant overlap between eating disorders and anxiety disorders, (especially Obsessive Compulsive Disorder).
Obsessive Compulsive Disorder
OCD is an anxiety disorder in which people have unwanted and repeated thoughts, feelings, images, and sensations (obsessions) and engage in behaviours or mental acts ( such as counting or reciting something) in response to these thoughts or obsessions; very often the person carries out the behaviours to reduce the impact or get rid of the obsessive thoughts, but this only brings temporary relief. Sound familiar? If you have an eating disorder, (or are supporting someone who does), chances are pretty high you'll be familiar with these sorts of behaviours to such an extent sometimes that it might be difficult to determine which of the two disorders that you, or your loved one, actually has, or even if both are simultaneously present.
A little background
Ever since 1939 researchers have speculated on these parallels between OCD and eating disorders. Numerous studies have now shown that those with eating disorders have much higher rates of OCD (11% – 69%), and vice versa (10% – 17%). As recently as 2004, a study found that a huge 64% of individuals with eating disorders also possess at least one anxiety disorder, and 41% of these individuals have OCD in particular. It's even been suggested that eating disorders should be considered part of the OCD spectrum.
OCD and Eating disorder behaviour overlap
We know that individuals who suffer from Anorexia (AN) restrict food intake and frequently exercise excessively; those with Bulimia (BN) usually develop a vicious cycle of bingeing and purging. In both instances, extreme and often life-threatening behaviours that consist of either consuming too little or too much food typically stem from intrusive, seemingly uncontrollable, obsessive thoughts, in particular, exhibit faulty perceptions of body image, an irrational fear of gaining weight, and other food-related obsessions thereby leading to the categorical refusal to eat.
As for people with BN, their disorder is characterised by a consumption of abnormally large quantities of food, followed by overwhelming feelings of guilt and shame. In other words, the sense of helplessness or lack of control they experience during binge periods ultimately gives way to obsessions of physical sickness and self-disgust afterwards.
In the cases of both AN and BN, obsessions lead to levels of anxiety that can only be reduced by ritualistic compulsions. The compulsive behaviours of those with AN can often be seen in their careful procedures of selecting, buying, preparing, cooking, ornamenting, and eventually consuming food. Just as with OCD, compulsions are commonly strengthened by many other personality traits, such as uncertainty, meticulousness, rigidity, and clinical perfectionism (there is such a thing!).
Those with AN also often show the same difficulty in understanding that their worries are baseless, which is typical of OCD, they show distorted thinking (like all-or-nothing thinking), and attempts to gain control of their environment.
Those fighting BN frequently experience the need to feel relieved of the obsessive guilt and shame following binges, which causes them to compulsively purge the food they consumed, repeating the cycle over and over again. Here too, perfectionism and, arguably, an excessive desire for social approval or acceptance, and bouts of anxiety or depression play a major role.
In both eating disorders, the individual clearly becomes preoccupied by incessant thoughts revolving around body image, weight gain, and food intake, leading to ritualistic methods of eating, restriction and exercising.
The common thread linking both of these disorders to OCD is the overwhelming presence of obsessions and compulsions that eventually affects the individual’s daily functioning, even to the extent of becoming incapacitated. Just as the OCD sufferer feels as though the door is not locked, despite evidence to the contrary, and is then compelled to check those locks hundreds of times in order to remove this doubt, so too someone with anorexia can feel compelled to constantly 'body check' to make sure that she has not gained weight, and is rarely, if ever, satisfied.
As with an OCD sufferer who can never achieve the sense of feeling free from uncertainty and anxiety on a specific task, so too is a BN sufferer prevented from ever really reaching their goals of 'feeling right', or of fullness and emptiness in an endless binge-purge cycle.
The overlap between the disorders can mean that GPs or therapists can misdiagnose an eating disorder when the client actually has an anxiety disorder, such as OCD . For example, a person sufferering from OCD may lose weight excessively and appear to have AN, yet is losing weight as the result of contamination concerns or time-consuming rituals that prevent him or her from eating on a regular basis.
On the flip side, consider the AN patient who seems to be engaging in obsessive-compulsive rituals of cutting or weighing food, yet only doing so in the hopes of restricting food intake and losing weight in the process.
The potential for one disorder to appear as the other is virtually endless; this article contains just a few of the different underlying causes of strikingly similar behaviours in individuals with obsessive-compulsive disorder and those with eating disorders.
Current treatments for OCD and ED
The recommended psychological treatment for both OCD and eating disorders usually involves some combination of cognitive-behavioural therapy, antidepressant medication, and family based therapy. Relapse rates have been found to be relatively high for eating disorder sufferers with classic CBT; this has led to the development of Enhanced CBT (CBT-E) , now recommended as standard treatment for both AN and BN by the National Institute of Clinical Excellence. Eating disorder Recovery coaching is becoming more widely used as a responsive, completely personalised approach, which includes many techniques including gradual alteration of eating rituals and increased flexibility in eating behaviours which may include breaking rituals such as the need to use the same plate, to measure out food, to time meals, or to chew all food a certain number of times.
Significant advancements have recently been made in both the diagnosis and treatment of eating disorders and OCD as separate disorders, but so far there hasn't been large-scale scientific research exploring in depth the connection between the two, the commonality of their symptoms, and their possible biochemical similarities.
Some promising studies in this area suggest that the two disorders could be linked by higher metabolism of glucose in the brain and so could have the common origins in neurobiological (nervous system) abnormalities. Although these studies are promising, more work is still need to properly understand and isolate all the factors, including clinical, biochemical and genetic, behind OCD and eating disorders.
By better understanding these disorders we can not only develop better treatment strategies, but also increase our understanding of the biological and psychological ways in which they develop.
Kaye WH, Bulik CM, Thornton L, Barbarich N, Masters K, “Comorbidity of anxiety disorders with anorexia and bulimia nervosa.” Am J Psychiatry, 2004; 161 2215-2221. *Yaryura-Tobias JA, & Neziroglu F (1983). “Obsessive Compulsive Disorders Pathogenesis Diagnosis and Treatment.” New York Marcel Dekker Yaryura-Tobias JA, Pinto A Neziroglu F. ‘The integration of primary anorexia nervosa and obsessive-compulsive disorder.” Eating Weight Disorder Journal, 2001; 6 174-180.
Murphy R, Nutzinger DO, Paul T, Leplow B. “Conditional-Associative Learning in Eating Disorders: A Comparison With OCD.” J Clinical and Experimental Neuropsychology, 2004; 26(2) 190-199. Mount R, Neziroglu F, Taylor CJ. “An obsessive-compulsive view of obesity and its treatment.” J Clinical Psychology, Jan. 1990; 46 (1) 68-78.