On numerous occasions over the 14 years that I have helped my clients with their psychological challenges, I have had many arrive at intake confused by what has been suggested as the problem area by well-meaning family, friends and other professionals. This has been especially true when symptoms overlap in multiple problem areas, looking like one thing and being quite another. After all, we are complex beings and everyone experiences their challenges differently. Feeling distress and immediately pointing to the cause isn’t simple. There are many things to consider especially when there is more than one issue that challenges us. However, sometimes separate problems are missed because the symptoms may look very similar or the identified primary problem causing the individual more suffering is what commands the attention. I see this most frequently in the case of co-occurring Anorexia or Bulimia with Obsessive-Compulsive Disorder.
Making a diagnosis can be challenging because the symptoms and behaviors of both disorders can look very similar. In fact, some argue that eating disorders are a form of OCD because there is an excessive presence of obsessions, ruminative thinking, compulsive rituals that help manage anxiety and distress to prevent a dreaded event, and behaviors that consume unreasonable amounts of time, making it hard to participate meaningfully in other important areas of life. However, the American Psychiatric Association has historically separated Eating Disorders from Obsessive-Compulsive Related Disorders recognizing that motivations differ. To illustrate the difference, your therapist considers if you are counting the number of times you cut your food because there is some magical number that will ameliorate anxiety or whether time is merely being wasted to avoid eating with the goal of losing weight. Is an excessive amount of weight being lost due to rituals that demand large parts of the day, such as excessive cleaning and washing the same load of clothes three times due to contamination fears, where the rituals simply don’t allow time to eat? Or are the obsessive-compulsive cleaning rituals a behavior to avoid eating due to an underlying fear of weight gain? While the answer to whether behaviors are related to OCD or an eating disorder lies in the motivation for the behavior, at times it isn’t clear, especially when both are present. For instance, thoughts to restrict may be intrusive and unwanted as in the case of OCD but at the same time the individual negatively evaluates weight and shape as in the case of an eating disorder.
While eating disorders and OCD possibly share similar neurobiological, genetic and psychological mechanisms, this does not suggest that those with OCD will develop an eating disorder and vice versa. However, when they do co-occur, treatment interventions suggested for eating disorders may differ from those effective in treating OCD and Anorexia or OCD and Bulimia. Therapists are continually faced with difficult diagnostic decisions when a constellation of symptoms present that align with multiple diagnoses. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, helps us to differentiate between potential diagnostic categories. After all, diagnosing accurately by teasing out subtle differences helps the therapist understand one’s struggles, history of the illness, risks and prognosis, which are all needed for a thorough conceptualization of what brings one to treatment and the development of a comprehensive treatment plan.
Therefore, diagnosing accurately and planning accordingly matter. As therapists we are often faced with complexity and integrating interventions to address multiple disorders. With proper diagnoses together with clinical experience, appropriate interventions and client-therapist collaboration, we work together compassionately to help our clients move away from the distress of co-occurring conditions and toward the quality of life they desire and deserve.