On a related note, a lack of response to high-dose SSRIs would technically not disqualify ED from being classified as an OCD spectrum disorder excoriation disorder (skin picking) and trichotillomania (hair pulling) are related disorders for which high-dose SSRIs lack efficacy evidence (Grant & Chamberlain, 2015). He adds that in treatment-resistant OCD, low-dose antipsychotics are only used to modify high-dose SSRIs but are never used on their own (Personal Communication, September 2022). OCD specialist Steven Poskar, MD, notes that if ED is a form of OCD, targeting eating-related obsessional thinking with antipsychotic monotherapy would not be indicated. Yet, in one review, 4 out of 9 guidelines for the treatment of ED consistently recommended the cautious use of antipsychotics (a different class of medication not used as a primary OCD treatment) for treating obsessional thinking in patients with anorexia nervosa (Hilbert et al., 2017). Perhaps because it is not thought of as OCD, the eating-related obsessions of ED are often not treated with high-dose SSRIs. When it comes to medication, considering ED and OCD as separate diagnoses might be appropriate if high-dose selective serotonin reuptake inhibitors (SSRIs) - the first-line medication for OCD - were ineffective for ED.To our current knowledge, we just do not have any studies to determine this precisely. Neuroscientific research stresses commonalities between ED and OCD (Gershkovich, Pascucci & Steinglass, 2017) but even if it did not, this type of research is not yet advanced enough to rely upon to make differential diagnoses (García-Gutiérrez et al., 2020). Returning to the issue at hand, does it make a difference if the focus of an obsession is limited to ED characteristics (e.g., feeding, shape, size, weight, or fatness), or something like contamination, as in OCD? OCD is not defined by its obsessional content but by its process - obsessions (discomforting, unwanted and repetitive thoughts, images or sensations), compulsions (avoidance behaviors done to neutralize them), at the negative cost of these on functioning and quality of life (APA, 2022). Every individual experience is unique, and must be addressed with attention, care, and integrity. We trust it is clear that we are not advocating that anyone being treated for ED should immediately run to an OCD treatment center. Using OCD concepts and modalities would be just one component of a comprehensive ED treatment plan, just as OCD treatment is more than ERP and medication, encompassing parent and family therapy (Demaria et al., 2021), attention to sociocultural factors (Abramowitz, 2013), therapeutic skill, and other modalities. In addition, we recognize well that EDs are highly complex and heterogeneous, and that not all may neatly fit into the OCD model - differentiating which do and do not and designing effective treatments for individuals in the “gray area” between ED and OCD is a crucial clinical and research challenge. We, the authors, agree and further argue from several perspectives that ED is fundamentally OCD with eating-related symptoms, focusing on factors such as feeding, shape, size, weight, and fatness.īefore diving in, we do not imply that reconsidering ED in an OCD framework would be a universal solution even with expert treatment, there are many with OCD who make limited or no progress (Fineberg et al., 2020). However, given so many shared characteristics, some researchers have believed that ED belongs in the OCD spectrum (e.g., Yaryura-Tobias and Neziroglu, 1983). This article was initially published in the Winter 2022 edition of the OCD Newsletter.Įating disorders (ED) and obsessive compulsive disorder (OCD) appear in separate chapters of the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) (American Psychiatric Association (APA), 2022) and are generally regarded as different conditions that often co-occur and share common symptoms, such as obsessional thinking, compulsions/rituals, avoidance behaviors, doubting, perfectionism, disgust, and personality factors (Palmer & Jones, 1939 Kaye et al., 2004 Simpson et al., 2013 Sternheim et al., 2017 Levinson et al., 2019 Brown et al., 2022). By Jonathan Hoffman, PhD, Dee Franklin, PsyD, LMHC, Ciana Mickolus, PsyD, & Myriam Padron, PsyD
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