Obsessive Compulsive Disorders

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Is "avoidance of fat people and things they ha[ve] touched" a form of obsessive compulsive disorder (OCD) (Greist and Jefferson 1995: 106)? It sounds like it may be an eating disorder, such as anorexia nervosa. It is difficult to tell which diagnosis would be appropriate in this situation, as there seems to be relatively little information concerning the dietary and nutritional dangers associated with obsessive compulsive disorder, especially when compared to anorexia. Might there be a link between modern society's "obsession" with the "perfect" body and the clinical diagnosis of OCD?

Anthony became very rigorous in his pursuit of weight loss . . . He has been following a highly structured routine . . . each morning . . . he eats a breakfast consisting of 1 ounce of cereal, 1 half cup of skim milk, 1 hard boiled egg, and strawberries or blueberries. He then waits a short period of time before proceeding to the weight room, where from Monday through Friday, he spends almost exactly 2 hours performing an identical routine of weight lifting . . . He skips lunch . . . and has a supper consisting of a sandwich, 6 ounces of yogurt, and iced tea. He does eat salads at times but is concerned about possible ill effects from pesticides that may have been applied to the vegetables. As a result of this ritualized regimen over the past several months, Anthony has lost 75 pounds, reportedly weighing 135 pounds . . . Anthony says he would prefer to weigh 145 pounds ... but is unable to eat the foods that would allow him to gain the weight.

(Greist and Jefferson 1995: 25)

This case seems difficult to classify. The DSM-IV-TR definition of OCD states:

an anxiety disorder, where it is defined as obsessions and/or compulsions that cause marked distress, are time-consuming, or interfere with functioning. Obsessions are defined as recurrent and persistent thoughts, impulses or images experienced as invasive and ego-dystonic and that cause anxiety or distress. Compulsions are defined as ritualistic behaviors or mental acts that the person feels driven to perform in response to an obsession or according to rules that must be rigidly applied. The behavior or mental act is aimed at preventing or reducing distress or preventing some dreaded event or situation and is recognized as excessive or unreasonable.

(American Psychiatric Association 2000: 417)

While Anthony's obsession with weight and subsequent compulsive diet and exercise regimen clearly match parts of the DSM-IV criteria for OCD, his behavioral symptoms seem also to mimic those of an eating disorder, namely anorexia.

The DSM-IV definition of anorexia nervosa has four conditions:

1) Refusal to maintain body weight for age and height; 2) intense fear of gaining weight or becoming fat, even though underweight; 3) disturbance in the way in which one's body weight, size, or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight; and 4) in females, amenorrhea.

(American Psychiatric Association 2000: 417-23)

This definition becomes important in understanding the relationship between anorexia and OCD, because in Anthony's case, for instance, his behaviors do superficially fit some of the DSM-IV criteria for anorexia. The DSM-IV condition that most applies to Anthony's situation is the first one mentioned above: Refusal to maintain body weight for age and height. However, when examined closely, Anthony does not truly meet these criteria, because he is not refusing to maintain healthy weight, in fact, "Anthony says he would prefer to weigh 145 pounds . . . but is unable to eat the foods that would allow him to gain the weight." This is due to an obsessive fear of the foods that would allow him to gain weight, rather than the intense fear of gaining weight associated with anorexia.

The key difference between OCD and anorexia is that people suffering from anorexia actually believe that they are too fat even when they are dangerously thin and, further, believe that their dangerously restrictive diet is "healthy." A person engaging in a dangerously restrictive diet associated with OCD, on the other hand, is well aware that their actions are "crazy" and can be debilitating; however, they are unable to refrain from performing such ritualistic dieting.

After close examination of Anthony's situation and the DSM-IV criteria for OCD and anorexia, it is clear that he is suffering from OCD and not anorexia. Thus, it is clear that OCD can have just as profound an effect on one's diet, exercise, and overall nutrition as any eating disorder. So why is there a lack of literature concerning the dietary and nutritional dangers that can be associated with OCD? Perhaps the answer has a great deal to do with the superficially gray areas linked to such cases (dangerously restrictive dieting associated with OCD).

Furthermore, the stigma of anorexia as untreatable may have something to do with misdiagnoses. Many patients labeled anorexic may, in fact, be suffering from OCD and are, as a result, often treated incorrectly, likely to no avail. Cases such as Anthony's further overlap with body dysmorphic disorder, which is related to a question asked above: Is there a link between modern society's "obsession" with fat and the perfect body and such obsessive compulsive (or body dysmorphic) tendencies.

Today, body dysmorphic disorder has reappeared as a conventional means of labeling men's obesity as a problem of obsession in the clinical sense—an OCD—rather than a failure of will (Gilman 2004: 228). In conclusion, OCD and its relationship with dieting and the pursuit of the perfect body has many unanswered questions, largely due to the gray areas and overlaps (with other mental illnesses) associated with it and, therefore, a great deal of additional research is necessary.

SLG/Jason Weinstein

See also Anorexia

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