On orthorexia, Part two: Orthorexia as a hybrid of OCD and anorexia?

In my previous blog post (which was, admittedly, ages ago), I talked about what orthorexia was and its close links with OCD. In my research for that post, I found a relatively new study that looked at the neuropsychiatric underpinnings of individuals with orthorexia to try and determine whether it should be classified as OCD or as an eating disorder.

On some level, this seems like pointless semantics. Let’s treat the disorder and sort diagnoses later. I’m a hardcore nerd who loves to think about these things and even I have those feelings. Yet the discussion is more than just academic. Understanding whether orthorexia is more OCD or more ED will give us clues as to better ways to treat the disorder. If it’s OCD, then exposure and response prevention, a type of cognitive behavioral therapy, should be at the top of the list for treatment approaches. If it’s ED, then re-nourishment and other types of psychotherapies might be prioritized. It also determines whether insurers or health systems will pay for treatment and in what venue. So in that sense, this discussion is important.

In a study in the journal Open Journal of Psychiatry, scientists Nancy S. Koven and Rina Senbonmatsu performed a neuropsychological tests on 100 young adults to determine levels of orthorexic beliefs and behaviors, as well as eating disordered and OCD thoughts and behaviors. They also measured other behaviors, such as intelligence, executive functioning, verbal learning and memory, cognitive flexibility, and set-shifting. The goal was to determine if patterns of thought in individuals endorsing high levels of orthorexic thoughts and behaviors were more similar to anorexia, OCD, or something in between.

In the introduction to the study, the authors point out the potential similarities between the three disorders:

At the symptom level, ON and AN share characteristics such as tendencies toward perfectionism, high comorbid anxiety, and need for control. Like individuals with AN, those with ON consider the ability to follow a restrictive diet to be an achievement of self-discipline and perceive deviation from that diet as a failure of self-control…In addition to AN traits, orthorexic individuals manifest obsessivecompulsive tendencies, such as carefully weighing and measuring food, extreme meal planning, and intrusive thoughts of food outside of meal time. Similar to OCD, ON interferes with the individual’s normal routines and social interactions. However, whereas the obsessions in OCD are perceived as ego-dystonic, the food-related thought content of individuals with ON is perceived as normal and appropriate.

{They didn’t have a citation for that last statement, and I couldn’t find any research on whether orthorexia was ego-syntonic or ego-dystonic, so interpret with caution.}

Koven and Senbonmatsu found that 21 participants (20 women) scored above the threshold for the orthorexia screening test. This does not mean that these individuals have orthorexia, just that they screened positive for it. A positive screen does not make a diagnosis!1

Analysis of the data revealed that the orthorexia group had higher levels of body dissatisfaction, perfectionism, and OCD symptoms. They also scored worse on measures of cognitive flexibility, such as the Wisconsin Card Sort Test. The authors conclude that orthorexia appears to be a combination of both anorexia and OCD. They conclude:

Taken together, it appears that ON is associated with similar cognitive correlates that are seen at the intersection of AN and OCD. Although some of the cognitive effects found in this sample are likely better explained by some combination of AN and OCD symptoms, an important finding is that ON symptoms are independently associated with aspects of executive functioning: set-shifting, self-monitoring, and working memory (WM). Interestingly, these areas of executive functioning represent what would be considered the neuropsychological overlap among OCD and AN profiles.

The study does have some significant limitations. For one, the study sample was primarily white university students, which could limit generalizability of the results. As well, it’s not a clinical sample. These are not individuals with orthorexia, OCD, or anorexia, just tendencies in those directions. So how well this holds up in individuals with these disorders isn’t clear.

Still, it provides some information about how to think about orthorexia and how to devise treatments. It appears that treating orthorexia as a co-occurring eating disorder and OCD might be a reasonable place to begin. Given that this is a frequent overlap seen in treatment, approaches to address both the ED- and OCD-specific aspects of orthorexia could be helpful.

1 This will be a blog post of its own!


Koven, N. S., & Senbonmatsu, R. (2013). A neuropsychological evaluation of orthorexia nervosa. Open Journal of PsychiatryDOI:10.4236/ojpsych.2013.32019

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9 Responses to “On orthorexia, Part two: Orthorexia as a hybrid of OCD and anorexia?”

  1. I found this fascinating because a new psychopharm suggested lamictal to me for my long-term struggle with bulimia. Because of it’s efficacy with OCD and his feeling that long term eating disorders have so many components.

    • Lamictal is a mood stabilizer and anti seizure med. While it’s a good drug (I took it for epilepsy), I’m not sure about its efficacy for OCD. Do you think he meant Luvox?

  2. I was convinced prior to our daughter’s diagnosis of RAN that she had Orthorexia. She exhibited all of the symptoms, and most importantly to a mother gripped in fear it meant she DIDN’T have Anorexia! At her evaluation at Kartini Clinic she was diagnosed with RAN and hospitalized that day. I recall inquiring to the possibility that perhaps it was really a case of Orthorexia. Dr. O’Toole gave me the impression that distinguishing between the two was splitting hairs. Two years later with all I’ve learned about eating disorders I agree. The possibility a non-eating disorder designation may allow a delay in appropriate treatment or allow a family to minimize the life threatening seriousness of the situation at hand would be things to consider.

  3. Great to read this. I know your concern is mostly about people getting the most likely effective treatment.

    You write “If it’s OCD, then exposure and response prevention …should be at the top of the list for treatment approaches. If it’s ED, then re-nourishment and other types of psychotherapies might be prioritized.”

    Did you have adults in mind, perhaps? For children and teens, to my knowledge, validated ED treatment is so much a form of exposure treatment anyway (Family-Based Treatment, priority given to normalising not just weight, but eating behaviour and exercising behaviour). Would you agree there’s not a big difference (and maybe that’s why in Patricia’s example, the Kartini Clinic saw it as splitting hairs)?

  4. Great post. Are you planning a follow-up with the recent study of prevalence of orthorexia among individuals recovering from an ED? It was a small, and kinda crappy study, but I had half the mind to blog about it. Let me know if you were going to do it as part of the series.

    Regarding whether it is important to differentiate as to whether it is more like OCD or more like an ED or whatever, a few things come to mind:

    First, I think that gets to the broader question of whether underlying causes (neurobiological or whatever) or self-perceived/ascribed intentions for the behaviours matter as far as treatment is concerned.

    Two, I wonder if there are differences when we look at whether individuals with ON have premorid EDs prior to ON. I wonder, are there differences (and if they are, do they matter) between those who develop what looks like (or is) ON during the process of recovery from an ED (so, perhaps it can construed as a stepping stone to healthier eating that’s midway between an ED and healthy eating, however you want to define those) whether the person is still holding on to some rigidity albeit in a different way AND those who develop it without any ED history, and then perhaps in those cases? (It is so freaking trendy to be gluten-free now-a-days.)

    I’m not in the camp who things body image distortions and “fear of fatness” is crucial to an ED diagnosis, although I get those who do. I am more in the camp who views ED behaviours as a way to manage anxiety and/or emotional distress of any kind. (I’m not super rigid about my membership in this camp though, I can see all sides, I think/hope) Consequently, I think if ON behaviours reduce extreme affective states, then we can *maybe* put ON and EDs in general into one broad category of anxiety disorders and treat them based on that framework.

    I don’t know. Anyway, I agree with your point on the previous post about lack of studies about ON in EDs. Seriously what. Turkish performance artists but not among ED folks? Huh.

    I do, however, think it is premature to think differences between ON and EDs are splitting hairs. Unsurprisingly, I disagree with a lot of what I’ve seen said by O’Toole. In fact, I think Kartini Clinic guidelines probably inadvertently promote ON behaviours in the long term with their whole avoidance of “junk food” for a year.

    • I can only speak for myself, but my ON behaviours were every bit as effective at blunting my anxiety as my AN behaviours, because for me it was just another sneaky way to keep my appetite at bay by eating less than I needed. Only ON behaviours got the stamp of approval from my health are professionals, whom I don’t think even knew to look for it or what damage it was causing.

  5. I developed the first signs of AN when I was 16, and full-blown AN at 18. From there, it morphed into ON. I was on my way to recovery at 21 (had gained weight to a normal BMI finally), but relapsed back to an unhealthy weight on a rigid diet fueled by ON.

    However, long before I started starving myself (I believe my ED was triggered in part by a stressful move), when I was eating everything I wanted and pleanty of it, I had very worrying OCD. I’ve had OCD since I was younger than 10 years old. It got much worse in puberty.

    I’m now 25, and have been in recovery for one year. I still get AN thoughts about my body, as well as OCD thoughts, and ON thoughts pretty regularly, but I’ve made a practice of resisting and relabeling them, so they aren’t as strong now.

    It is kind of funny, but when I was confronting my ON fears of X type of food (one by one) over a period of a few months, my OCD flared up a bit more than usual–once I’d label a fear food as “nourishment, nt unhealthy” and go to eat it, I ‘d suddenly think my food was poisoned want to throw it up. I also developed the compulsion to rinse my clean dishes, and fear of certain plates in the household.

    All that to say, I think this topic is very interesting! Hopefully science will continue to learn more about how these disorders interact.

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