anorexia and ocd case study

• From the Experts

These articles are about special topics related to OCD and related disorders. For more general information, please visit our "About OCD" section.

The Relationship Between Eating Disorders and OCD Part of the Spectrum

By Fugen Neziroglu, PhD, ABBP, ABPP and Jonathan Sandler, BA

This article was initially published in the Summer 2009 edition of the OCD Newsletter . 

When people think of eating disorders, they conjure up images of adolescents performing rituals around food and obsessing about what to eat, how much, whether the food will be easily digested or whether the food will sit in their stomachs and make them look ugly. Others think of individuals with eating disorders appearing very similar to those with body dysmorphic disorder, both being very preoccupied with their body image. However, most people do not think of eating disorders as being part of the OCD spectrum, and the relationship between the two disorders has gone relatively unstudied. Even more troubling is the fact that when patients seek help from mental health professionals in order to alleviate their suffering, clinicians may often mistake one for the other. In other words, since the behaviors that result from both OCD and eating disorders may appear so similar, it might be difficult to determine which of the two disorders the patient actually has if both are simultaneously present, and if so, which disorder is mainly responsible for bringing about the other.

Ever since 1939 researchers have speculated on the parallels between OCD and eating disorders. Numerous studies have now shown that those with eating disorders have statistically higher rates of OCD (11% – 69%), and vice versa (10% – 17%). As recently as 2004, Kaye, et al., reported that 64% of individuals with eating disorders also possess at least one anxiety disorder, and 41% of these individuals have OCD in particular. In 1983, Yaryura-Tobias and Neziroglu proposed that eating disorders may be considered part of the OCD spectrumm but since then the boundaries among anorexia, nervosa, bulimia nervosa, and OCD remain blurred. Thus, the challenge for clinicians becomes recognizing whether the condition is a particular form of OCD, or actually an entirely separate but related disorder with symptoms that merely have an obsessive-compulsive quality to them. More specifically, individuals who suffer from anorexia commonly diet and exercise excessively; those with bulimia usually develop a vicious cycle of binging and purging. In both instances, extreme and often life-threatening behaviors that consist of either consuming too little or too much food typically stem from intrusive obsessive thoughts. Anorexics, 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 bulimics, their disorder is characterized 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 anorexia and bulimia, obsessions lead to levels of anxiety that can only be reduced by ritualistic compulsions. The compulsive behaviors of anorexics 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 perfectionism (Yaryura-Tobiast al. 2001). Anorexics also often exhibit overvalued ideation, cognitive distortions, such as all-or-none thinking, and attempts to gain control of their environment. For bulimics, the need to feel relieved of the obsessive guilt and shame following binges causes them to compulsively purge the food they consumed, repeating the cycle over and over again. Here too, perfectionism an excessive desire for social approval or acceptance, and bouts of anxiety or depression play a major role.

In both anorexia and bulimia the individual clearly becomes preoccupied by incessant thoughts revolving around body image, weight gain, and food intake, leading to ritualistic methods of eating dieting 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 the anorexic feels as though she is fat despite the reality the mirror portrays, and she is thus forever checking her stomach to make sure that she has not gained weight, but she is never satisfied and therefore she is compelled to lose weight by any means necessary. As with an OCD sufferer who can never achieve that “just right” feeling on a specific task, so too is a bulimic prevented from ever reaching his or her goals of fullness and emptiness in an endless binge-purge cycle. Going one step further there are many instances in which patients demonstrate behaviors that at first glance appear to be indicative of an eating disorder, but actually turn out to be a result of OCD. As an illustration, consider the OCD sufferer who may lose weight excessively and appear anorexic yet is doing so merely as the result of contamination concerns or time-consuming rituals that prevent him or her from eating on a regular basis. Conversely, consider the anorexic 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; below is just a small list comparing the very different underlying causes of strikingly similar behaviors in individuals with obsessive-compulsive disorder versus those with eating disorders.

Obsessive Compulsive Disorder Eating Disorders

Individual counts the number of mouthfuls chewed or pieces of food in a meal according to some fixed or magical number that is “correct” or “just right.” Individual counts mouthfuls or pieces of food as a means of limiting portions, and thus effectively losing more weight. Individual repeatedly washes hands due to a fear of germs, contact with waste products, or a number of other sources of possible contamination that exist. Individual excessively washes hands to remove trace amounts of oil that might cause weight gain if ingested. Individual throws out food in a can that has been slightly dented for fear that it might contain food poisoning and later cause serious illness to someone. Individual throws out food in a can because it was discovered to contain too many calories after reading the label. Individual repeatedly asks a waiter in a restaurant about different dishes on menu doubtful that he or she has enough knowledge to make the perfect meal decision. Individual constantly asks same waiter about contents of dishes so as to stay away from having any butter oil or fat. Individual refuses to enter the kitchen in order to eat due to fear of accidentally mixing cleaning items with the food. Individual refuses to enter the same room for it will only lead to the temptation to eat and thus get fat. Individual repeatedly checks refrigerator shelves or other parts of house in order to make sure that every piece of food bought is in its proper designated place. Individual constantly checks same locations in search of food to eat in an extensive bulimic binge period.

Thus in order to differentiate between the two disorders and make the proper diagnosis, it is crucial for the clinician to more closely examine the specific behaviors that are being observed and the motivations behind those behaviors. Whereas patients with eating disorders are primarily driven by concerns of physical appearance, and consequently alter their eating patterns in order to lose weight accordingly. OCD patients may be restricting their eating for reasons very different than body image concerns. Furthermore, for cases in which an individual qualifies for both diagnoses, such as an anorexic or bulimic who also experiences non-food related OCD symptoms, like checking or contamination, it is still imperative to consider whether or not their symptoms are being motivated by both disorders simultaneously. For example, consider a patient washing his/her groceries due to the fear of contamination as well as the fear that the products may contain high fat ingredients.

It should be noted that the recommended psychological treatment for both OCD and eating disorders usually involves some combination of cognitive-behavioral therapy, antidepressant medication, and family counseling. Successful treatment for bulimics in particular often entails classic exposure and response prevention, in which patients are exposed to their favorite foods, asked to eat, and then prevented with careful monitoring from vomiting using laxatives or otherwise purging. Additional techniques involve gradual alteration of eating rituals and increased flexibility in eating behaviors which may include breaking rituals such as the need to use the same utensils to measure food, to time meals, and to avoid certain restaurants. Because eating disorders typically result in numerous medical complications, we strongly encourage physicians and nutritionists to be part of the team.

Significant advancements have recently been made in both the diagnosis and treatment of OCD and eating disorders as separate entities, but ample scientific research into the connection between the two, the commonality of their symptoms, and the possible biochemical similarities behind, them is presently lacking. Fortunately, some of the most promising psychiatric investigations into the overlapping symptoms of spectrum disorders have focused on these neurophysiological similarities. One such study asked participants to engage in a task believed to activate the prefrontal cortex and caudate nucleus of the brain so as to compare the performance of participants with OCD to that of those with anorexia. The study found that both groups had difficulty with the task and had higher cerebral glucose metabolism, suggesting a connection between the two disorders and offering evidence that, “ritualized obsessive and compulsive behavior (with reference to eating disorders, as well as washing and checking OCD) could have its origin within common neurobiological abnormalities,” (Murphy, et al. 2004). Although such results are clearly signs of progress, they are still indirect and speculative at best. More work is therefore needed in order to properly isolate the clinical symptoms, biochemical factors, and genetic causes behind OCD and eating disorders. In one of our studies we found that obsessive-compulsive overeaters responded to exposure and response prevention, while another group of overeaters responded better to more traditional stimulus control methods of treatment (Mount & Nezirogulu 1991). This shows that those eating disorders that are similar to OCD may respond better to treatment strategies used to treat more typical OCD behaviors. Consequently, for the sake of all those who suffer the obsessive-compulsive related disorders need to be studied further in order to enhance our understanding of their similarities and dissimilarities. In doing so we will hopefully not only arrive at better treatment strategies but also increase our knowledge of the psychological and biological mechanisms by which the disorders develop.

Fugen Neziroglu, PhD, is a board certified Behavior and Cognitive psychologist involved in the research and treatment of OCD for 25 years. She is the Clinical Director of the Bio-Behavioral Institute in Great Neck, NY and Professor at Hofstra University.

Jonathan Sandler, BA is a research assistant at the Bio-Behavioral Institute in Great Neck, NY and he is involved in the research of Obsessive Compulsive Spectrum Disorders.

1. 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. 2. Yaryura-Tobias JA, & Neziroglu F (1983). “Obsessive Compulsive Disorders Pathogenesis Diagnosis and Treatment.” New York Marcel Dekker 3. 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. 4. 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. 5. Mount R, Neziroglu F, Taylor CJ. “An obsessive-compulsive view of obesity and its treatment.” J Clinical Psychology, Jan. 1990; 46 (1) 68-78.

In This Section

More resources.

• Fact Sheets & Brochures
• Books About OCD
• Educational Resources

Search iocdf.org

Your gift has the power to change the life of someone living with ocd..

Etiological overlap between obsessive-compulsive disorder and anorexia nervosa: a longitudinal cohort, multigenerational family and twin study

Affiliations.

• 1 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
• 2 Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
• 3 Department of Clinical Neuroscience, Centre for Psychiatric Research and Education, Karolinska Institutet and Stockholm County Council, Stockholm, Sweden.
• 4 Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
• PMID: 26407789
• PMCID: PMC4592656
• DOI: 10.1002/wps.20251

Obsessive-compulsive disorder (OCD) often co-occurs with anorexia nervosa (AN), a comorbid profile that complicates the clinical management of both conditions. This population-based study aimed to examine patterns of comorbidity, longitudinal risks, shared familial risks and shared genetic factors between OCD and AN at the population level. Participants were individuals with a diagnosis of OCD (N=19,814) or AN (N=8,462) in the Swedish National Patient Register between January 1992 and December 2009; their first-, second- and third-degree relatives; and population-matched (1:10 ratio) unaffected comparison individuals and their relatives. Female twins from the population-based Swedish Twin Register (N=8,550) were also included. Females with OCD had a 16-fold increased risk of having a comorbid diagnosis of AN, whereas males with OCD had a 37-fold increased risk. Longitudinal analyses showed that individuals first diagnosed with OCD had an increased risk for a later diagnosis of AN (risk ratio, RR=3.6), whereas individuals first diagnosed with AN had an even greater risk for a later diagnosis of OCD (RR=9.6). These longitudinal risks were about twice as high for males than for females. First- and second-degree relatives of probands with OCD had an increased risk for AN, and the magnitude of this risk tended to increase with the degree of genetic relatedness. Bivariate twin models revealed a moderate but significant degree of genetic overlap between self-reported OCD and AN diagnoses (ra =0.52, 95% CI: 0.26-0.81), but most of the genetic variance was disorder-specific. The moderately high genetic correlation supports the idea that this frequently observed comorbid pattern is at least in part due to shared genetic factors, though disorder-specific factors are more important. These results have implications for current gene-searching efforts and for clinical practice.

Keywords: Obsessive-compulsive disorder; anorexia nervosa; comorbidity; eating disorders; genetic epidemiology; shared genetic factors.

© 2015 World Psychiatric Association.

• Open access
• Published: 02 May 2013

The relationship between obsessive-compulsive personality disorder traits, obsessive-compulsive disorder and excessive exercise in patients with anorexia nervosa: a systematic review

• Sarah Young 1 ,
• Paul Rhodes 1 ,
• Stephen Touyz 1 &
• Phillipa Hay 2 , 3  

Journal of Eating Disorders volume  1 , Article number:  16 ( 2013 ) Cite this article

35k Accesses

26 Citations

22 Altmetric

Metrics details

Obsessive-compulsive personality disorder (OCPD) traits and obsessive-compulsive disorder (OCD) are commonly associated with patients with Anorexia Nervosa (AN). The aim of this review was to systematically search the literature to examine whether OCPD and OCD are positively associated with excessive exercise in patients with AN.

A systematic electronic search of the literature (using PsycInfo, Medline and Web of Knowledge) was undertaken to identify relevant publications until May 2012.

A total of ten studies met criteria for inclusion in the review. The design of the studies varied from cross-sectional to retrospective and quasi-experimental. Seven out of the ten studies reviewed demonstrated a positive relationship between OCPD and/or OCD in AN patients who exercise excessively, whilst three studies found a lack of relationship, or a negative relationship, between these constructs.

There is evidence from the literature to suggest that there is a positive relationship between OCPD and excessive exercise in patients with AN. However, the relationship between OCD and excessive exercise is less clear and further research is required to qualify the strength of such relationships. Future research should utilise the most comprehensive and reliable clinical assessment tools, and address prognostic factors, treatment factors and specific interventions for patients with OCPD and/or OCD and excessive exercise.

Anorexia Nervosa (AN) is recognised as one of the most serious chronic mental illnesses, with significant physical and psychosocial consequences [ 1 ]. In order to reduce burden of illness, increased understanding of developmental and maintaining factors of AN is required. The relationship between obsessionality and AN has been observed for a number of decades. However, research is yet to determine the distinct nature of this relationship and the putative moderating effect of excessive exercise [ 2 ].

Rothenberg [ 3 ] proposed that eating disorders are a “variant” of Obsessive-Compulsive Disorder (OCD), evidenced by high comorbidity between OCD and AN [ 4 – 6 ] and reporting of obsessional symptoms in AN patients [ 7 ]. AN patients follow strict food and exercise routines, and commonly present with obsessions of contamination and symmetry as well as compulsions of checking and counting [ 8 – 10 ]. There is also some neuro-chemical evidence for the relationship, with altered serotonergic function (5-HT) apparent in OCD and AN [ 11 ]. Although Obsessive-Compulsive Personality Disorder (OCPD) and OCD are recognised as distinct clinical syndromes, research has shown they significantly overlap in the risk profile for AN [ 12 , 13 ]. Yet, in their genetic studies, Lilenfeld, Kaye and colleagues demonstrated that while there was no shared causative factor for OCD and eating disorders within families, OCPD traits were demonstrated to be a specific familial risk factor for anorexia nervosa [ 14 ]. AN patients demonstrate personality traits which are highly concordant with OCPD- perfectionism, rigidity, higher impulse control and emotional restraint [ 15 , 16 ]. However, causal inferences are difficult to determine with obsessionality compounded by starvation effects [ 17 ]. AN patients show minimal changes in obsessional personality characteristics following weight restoration [ 18 ], suggesting that such pre-morbid personality traits play a role in the pathogenesis of AN [ 2 ].

Excessive exercise plays a detrimental role in the pathogenesis and maintenance of AN [ 19 – 21 ], and features in up to 80% of patients with AN [ 22 ]. The inverse relationship between reduced dietary intake and increased physical activity or hyperactivity- referred to as “activity anorexia” [ 23 ] was proposed as a bio-behavioural model of AN [ 21 ]. The presence of feeling “guilty” if an exercise session is missed is central to an eating disorder, signifying the obligatory nature of the behaviour [ 24 ] (also see [ 25 , 26 ] for models of the relationship between exercise dependence and eating pathology). Excessive exercise in AN has been associated with detrimental factors including: higher energy requirements for re-feeding/weight-gain [ 27 ]; elevated psychopathology [ 28 ]; and higher rates of relapse after recovery [ 29 ]. Based on the prognostic characteristics of excessive exercise, research has aimed to identify personality and psychological variables associated with this construct. AN patients who exercise excessively report higher levels of depression, anxiety and perfectionism [ 30 , 31 ], but potential relationships between excessive exercise and other psychological variables are thus far unclear.

Rationale for the current review

The reviewed research suggests that AN is associated with increased OCD symptomatology and a higher prevalence of OCPD traits. Research is warranted to determine personality and psychological variables for excessive exercise, in particular those that may be remedial to interventions [ 32 ]. The aims are to critically examine evidence as to whether OCPD traits and/or OCD are associated with excessive exercise in AN, and to determine the nature of such relationships between these constructs in patients with AN.

Search strategy

The search strategy was designed to identify all studies of patients with AN, in which OCPD or its traits, or OCD and its features were formally assessed, and in which excessive exercise was formally measured through clinical interview or clinical judgement.

The following databases were systematically searched from April-beginning of May 2012: PsycINFO (1806-present), Medline (1950-present) and Web of Knowledge (1864-present). Reference lists from relevant articles were also manually searched for additional studies. The following search terms were used: (anorexia* OR anore* OR eating disorder*) AND (exercise* OR excessive exercise* OR exercise abuse* OR over-exercise* OR compulsive exercise* OR exercise dependen* OR physical activit*) AND (personalit* OR obsessiv* OR obsessive compulsiv* OR compulsiv* OR OCD). Peer-reviewed research articles that focused on the relationship between exercise and obsessive compulsive disorder and/or obsessive compulsive personality traits in patients with anorexia nervosa were included. A total of 443 papers were retrieved from the electronic search. The titles and abstracts were screened to assess the suitability of papers. A second reviewer also screened a proportion of the titles and abstract to reduce selection bias. 79 papers were excluded from their title, and 302 papers were excluded from their abstract. The full text of 62 papers was read, and 54 were excluded. The reference lists of the final full text papers were searched manually, and a further two articles were retrieved. The second reviewer also read full texts of papers meeting the inclusion criteria, and there were no discrepancies in the inclusion of articles, thus a total of 10 studies were included in the review.

Selection of studies

A detailed map of the search strategy can be seen in Figure  1 . Papers were selected if: a) study was written (or available) in English; b) participants fulfilled standard DSM-IV-TR, DSM-IV, DSM-III or ICD-10 current or lifetime diagnosis criteria for AN; c) participants were assessed as having excessive exercise as a feature of their eating disorder; d) participants were assessed for OCPD traits or OCD symptoms/features using established scales/interview methods. Papers had to be published in peer reviewed journals, thus abstracts and dissertations were not included. There were no restrictions made on publication year, age or gender of participants, although the literature’s focus on females was aligned with current and historical low prevalence rates of AN in males. No restrictions were placed on participant’s Body Mass Index (BMI), the chronicity of illness in the sample, or the type of treatment received. Studies were excluded if the sample did not contain a group of patients with AN (if sample only included patients with Bulimia Nervosa or Eating Disorder Not Otherwise Specified). Studies were also excluded if they did not include a clinical sample: for example, only community samples, samples from university population or athlete samples without a sample of patients with diagnosed eating disorders.

Flow chart of article retrieval process.

Quality assessment

The final retrieved articles underwent quality assessment utilising an amended version of the original Quality Index by Downs and Black [ 33 ]. The Quality Index is a reliable tool for measuring the methodological quality of epidemiological and health research [ 33 ]. This index had been amended by Ferro and Speechley [ 34 ] for their systematic review in the health science field. For their review, they excluded the assessment of quality items addressing characteristics of intervention studies, such as blinding, randomisation, withdrawals and drop-outs and integrity of intervention. The amended version resulted in 15 items (see Table  1 ). Each checklist item was scored 0 (No or Unable to Determine), or 1 (Yes). The maximum score was 15. A higher score indicated greater methodological rigour.

Description of studies

A total of ten studies were reviewed: four studies utilised AN participants who were receiving inpatient treatment; three studies used inpatients and outpatients; one study used outpatients only, whilst another study stated that they recruited from four eating disorder services, but did not specify the settings. The final study included patients with AN who were from the multisite international Price Foundation Study of AN, BN and AN Trios studies, and their affected relatives who met lifetime diagnosis of AN (see Tables  2 and 3 for a summary of the studies). Studies were conducted in a number of countries, including USA, Canada, Germany and Spain. Two other studies were conducted across more than one treatment site, such as in Slovenia and the UK. The majority of studies employed cross-sectional designs. One paper utilised a prospective design [ 38 ] and two used a retrospective design [ 31 , 35 ]. The final study was quasi-experimental [ 2 ].

The total mean score on the Quality Index was 11.2/15 and scores ranged from 9–13. Refer to Table  1 for the quality assessment of each study. The mean subscale scores were 5.9/7.0 (range 5–7) for reporting, 1.2/3.0 (range 0–2) for external validity and 4.0/4.0 for internal validity. One study reported a power calculation.

Measures used

Objective measures of height and weight were collected in all studies. Structured interview schedules for exercise behaviours included different versions of the Eating Disorder Examination (EDE) interview [ 44 ]. These structured interviews assessed the exercise behavior of the participant over the past three months, asking about exercise that was “obligatory” or “obsessive” or “driven”, and engaged in for the purpose of burning calories/kilojoules or weight control. The Structured Interview for Anorexic and Bulimic Disorders (SIAB) from DSM-IV and ICD-10 [ 59 ] was used in other studies to separate excessive from non-excessive exercisers, through the endorsement of any of the following categories of exercise behaviour: 1) severe interference with important activities; 2) exercising more than 3 hours/day and distress if unable to exercise; 3) frequent exercise at inappropriate times and places; and 4) exercising despite illness, injury or medical complications. Other measures were questionnaires including the Commitment to Exercise Scale (CES: [ 55 ]) which assesses the obligatory pathological aspects of exercise and the Compulsive Exercise Test (CET: [ 32 ]) which assesses avoidance and rule-driven behavior, weight control exercise, lack of exercise enjoyment, mood improvement, guilt, negative and positive reinforcement of exercise, and behavioural rigidity.

Other assessment protocol for excessive exercise included questions regarding duration, frequency and intensity of exercise per week [ 2 , 21 , 30 ] and questions of lifetime exercise status.

OCD symptomatology was measured using different self-report questionnaires. The OBQ-44 assessed constructs of inflated responsibility/threat estimation, perfectionism/tolerance of uncertainty, and importance/control of thoughts [ 61 ]. The Obsessive Compulsive Inventory-Revised [ 62 ] was utilised to assess the distress associated with symptoms of OCD, such as checking, washing, obsessing and ordering. The Padua Inventory [ 49 ], Yale-Brown Obsessive Compulsive Scale [ 70 ] and the Maudsley Obsessive-Compulsive Inventory [ 53 ] measured similar constructs to the OCI-R. A number of other studies used the Symptom Checklist-90-R [ 66 ] to measure obsessive-compulsive symptoms.

OCPD traits were measured through a number of methods. The EATATE interview [ 43 ] was included in one study to assess for obsessive-compulsive traits in childhood (such as perfectionism, drive for order and symmetry, and excessive doubt). Two other studies used an inventory designed to assess the “obsessional” personality type derived from psychoanalytic theory as a measure of obsessive-compulsive personality traits [ 52 ], and two studies used the Multidimensional Perfectionism Scale [ 54 ] to measure perfectionism, demonstrated to be one of the main temperamental characteristics of AN [ 72 ].

Relationship between excessive exercise and OCD symptomatology

Davis and Kaptein [ 38 ] demonstrated that patients who were identified as excessive exercisers showed higher number of obsessive-compulsive symptoms ( p  = .007) than non-excessive exercisers, unaffected by dietary status. Both excessive exercisers and non-excessive exercisers demonstrated a reduction in OCD symptoms between admission and discharge ( p < . 001). There was an interaction trend demonstrating that, after re-feeding, OC symptoms decreased less in the excessive exercisers group. It was also noted that patients who presented with excessive exercise reported a higher number of obsessive compulsive symptoms on the Maudsley Obsessive Compulsive Inventory (at admission and discharge) than a group of patients diagnosed with OCD [ 73 ].

Similar findings were demonstrated in studies by Davis et al. [ 2 , 39 ] in which AN patients who exercised excessively reported more obligatory and pathological attitudes towards exercise ( p  < .01). Obsessive-compulsiveness was positively related to level of activity in AN patients ( p < . 01) and exercising participants also demonstrated higher OC symptomatology than non-exercisers ( p  = .02).

Naylor et al. [ 41 ] concluded that women with AN who had higher levels of beliefs of exercise behaviour also had higher levels of obsessive beliefs ( p  < .01), obsessive-compulsive behaviours ( p  < .01), as well as higher eating disorder psychopathology ( p  < .01). Specifically, the Checking subscale from the OCI-R contributed uniquely and significantly to the overall model explaining weight control exercise, signifying that these obsessive beliefs and behaviours predict the variance in exercise for purpose of weight control, after controlling for eating disorder psychopathology. Furthermore, Shroff et al. [ 42 ] reported that excessive exercise was associated with higher frequency and intensity of rituals and preoccupations ( p  < .001), and higher frequency of obsessions and compulsions ( p  < .001), when compared with AN patients who completed no or regular exercise.

However, Anderluh et al. [ 35 ] found no differences between groups in frequency of current or lifetime OCD. Bewell-Weiss & Carter [ 36 ] demonstrated that although self-esteem and depressive symptomatology were positively associated with exercise, obsessive compulsive symptomatology was negatively associated with exercise status ( p  = .038). Penas-Lledo et al. [ 31 ] found that OCD symptoms were not significantly higher in patients who exercised excessively when compared with those who did not ( p  > .05). Finally, Holtkamp et al. [ 40 ] concluded that obsessive-compulsiveness was not associated with physical activity levels ( p  = .705) and that obsessive-compulsiveness was not a significant contributor in the regression model predicting physical activity with other factors such as BMI, level of food restriction, depression and anxiety.

Relationship between excessive exercise and OCPD traits

Davis and Kaptein [ 38 ] demonstrated that patients who were excessive exercisers showed a higher number of obsessive-compulsive personality traits, both currently and historically throughout their disorder ( p  = .03) than non excessive exercisers, and this was unaffected by dietary status.

Davis et al. [ 2 ] showed that excessive exercisers had higher OC personality characteristics ( p  < .05) and levels of self-oriented perfectionism ( p < . 05) than non-excessive exercisers. Anderluh et al. [ 35 ] reported that patients with AN who exercised excessively had a higher prevalence of OCPD traits during childhood such as being rule bound ( p <  .005) and cautious ( p < . 02), however they did not find any significant differences in current OCPD comorbidity ( p  > .05).

Davis and Claridge [ 37 ] demonstrated that obsessive-compulsive personality traits were positively associated with over-exercising, both in current excessive exercising ( p  < .05) and historically throughout the eating disorder ( p  < .01). Furthermore, Shroff et al. [ 42 ] reported that excessive exercise was associated with significantly greater perfectionism ( p  < .001), measuring factors such as concern over mistakes, personal standards, organisation and parental criticism.

The aims of this systematic review were to critically examine evidence as to whether OCPD traits and/or OCD are associated with excessive exercise in patients with AN, and to determine the nature of relationships between these constructs. The results of the systematic review indicated a positive relationship between excessive exercise and obsessive-compulsive personality traits. However, the relationship between OCD and excessive exercise in AN patients is less clear with studies producing varying results.

Davis et al. [ 39 ] proposed a theoretical model of the relationship between starvation, physical activity and obsessive-compulsiveness in the development of eating disorders for some patients. This model works on the understanding that significantly reduced dietary intake and increased physical activity, combined with OCD features, create a mutually reinforcing, destructive mechanism which may play an integral role in the development and maintenance of an eating disorder [ 39 ]. The results of this review also seem consistent with the theory of “activity anorexia” [ 23 ], providing preliminary evidence for this phenomenon in human samples. Results have also supported the notion that high level exercising and reduced dietary intake alter the functioning of 5-HT with increased OCD symptomatology [ 2 ], creating a cycle whereby the individual undertakes an even higher level of physical activity and decreases their dietary intake as their obsessions increase [ 39 ].

Furthermore, the findings of Naylor et al. [ 41 ] are consistent with research examining the reduction in quality of life for these patients [ 74 ] and descriptions of their exercise being “out of control” [ 39 ]. Having obsessive beliefs and compulsions was a significant predictor in the regression model for exercise beliefs, after controlling for BMI and eating disorder psychopathology [ 41 ]. Such findings are consistent with the premise that obsessionality plays a causal role in the development and maintenance of excessive exercise [ 38 ].

Bewell-Weiss and Carter [ 36 ] reported a negative relationship between OCD symptomatology and excessive exercise. The researchers concluded that it may have been that their regression model was more comprehensive than those used in previous studies, or that obsessive-compulsive symptomatology had shared variance with another variable that had not been explored with previous studies [ 36 ]. Additionally, they used different OCD measures than those used in other studies [ 36 ]. Penas-Lledo et al. [ 31 ] found a trend only for increased obsessive compulsive symptomatology in exercising patients using the SCL-90-R. Finally, Hotlkamp et al. [ 40 ] found no direct relationship between obsessive-compulsiveness and levels of physical activity, also assessed using the SCL-90-R. It may be that this measure is not as sensitive as other measures, or that OCD features affect cognitions or beliefs about exercise [ 40 ].

Davis et al. [ 2 ] speculated that it could be that greater obsessive-compulsive personality traits are exacerbated by the combination of starvation and high level exercise, or that these patients choose to combine dietary restraint with excessive exercise. It may be the case that patients who have obsessive tendencies are more likely to undertake exercise as an additional method to prevent weight gain (on top of restricted diet, purging behaviour) or to neutralise fears of changes in their body weight and shape [ 75 ]. Alternatively, patients may be using exercise to alleviate or reduce anxiety [ 76 ], or as a means of neutralising predominant weight or food related obsessions [ 40 ].

Anderluh et al. [ 35 ] found that participants with childhood traits of rigidity, extreme cautiousness and perfectionism underwent more severe food restriction and higher levels of excessive exercise, and experienced longer periods of underweight status. Their research identified the possibility of homogenous phenotypes of AN and demonstrates that premorbid obsessive-compulsive personality traits in childhood may influence the course of the eating disorder later in life, potentially contributing to a more severe form of restricting AN, which could be extremely resistant to treatment [ 38 ].

There are a number of limitations that were evident in the reviewed literature. The number of studies examined in the review (10) is small, and results must be interpreted with some caution as some of the studies did not support the association between OCD and excessive exercise. A number of the reviewed studies did not clearly differentiate between OCD and OCPD constructs in their presentation of results. Nine different types of measures were employed across the studies to assess OCPD traits and OCD symptomatology, many of these being self-report questionnaires, which may increase the incidence of socially desirable response styles. Others involved expert clinical assessment in the form of an interview (for example, the EATATE interview in Anderluh et al. [ 35 ]). These various instruments assess different constructs, and some measures may have provided more detailed information, both of which may have biased the results. In one study, the use of the SCL-90 may have been inappropriate, as it had been normed for participants aged 14 years and older, yet a proportion of their sample were aged between 13 and 14 years. It would thus be beneficial for future studies to utilise the most current and comprehensive assessment tools in the field to enable more reliable inter-study comparisons.

Denial commonly occurs in anorexia nervosa, and subjective measures may have underestimated the amount of physical activity completed by patients. Such underestimation may have led to significant bias and consequently inaccuracy of data regarding the extent of exercise, and its relationships with coexisting OCD and/or OCPD. This potential room for bias has led to the utilisation of more objective means of assessing for physical activity in patients with AN, for example accelerometers [ 77 , 78 ]. Yet no study included in the review used such devices. Numerous measures of exercise were utilised across studies, reflecting both the variety of measures available, and the time period over which the studies were undertaken (1995–2011). However, there is also a pervasive issue in this field regarding the lack of consensus on what defines excessive exercise, how it should be measured and how it should be managed in patients with AN [ 79 ].

There are also a number of limitations in regards to participants utilised in the studies. The small sample size of Holtkamp et al. [ 40 ] affected their capability to generalise their results, whilst the use of informants may have been beneficial for Anderluh et al. [ 35 ] to confirm retrospective data provided by participants and to limit memory bias effects. Participants across studies who were inpatients were not exercising at the time of completing study assessments and questionnaires, and it is unknown what effect this may have had on response style. Other participants (for example outpatients) would not have such intense restrictions. The research reviewed also did not take into account other factors which may be important in the study of obsessive-compulsive symptomatology with excessive exercisers, such as motivational factors and specific reasons for exercising (other than the use of CET in Naylor et al., [ 41 ]). Finally, across studies, the patients were recruited mostly from secondary and tertiary referral services, i.e. inpatient and outpatient eating disorder services. Thus, the findings from the review cannot be generalised to people with AN who are currently not seeking treatment, or whose eating disorder pathology is not as severe as those patients in hospital treatment.

As the vast majority of the studies employed a cross-sectional design, only relationships between variables could be determined, and there can be no demonstration of the direction of such associations. Acute starvation syndrome and severity of eating disorder psychopathology both have significant impact upon level of obsessive-compulsive symptoms and exercise [ 17 ]. There was also no information about how obsessionality might affect prognosis and treatment outcome for AN patients who exercise excessively.

Whilst this review has focused on the relationships between OCPD traits and/or OCD symptomatology with excessive exercise in patients with AN, it would be remiss not to mention the significant relationships which excessive exercise shares with other psychopathologies, which have important implications for treatment. Studies included in the review demonstrated that AN patients who exercised excessively demonstrated lower minimum BMI and lower novelty seeking, but higher harm avoidance, persistence and cooperativeness [ 42 ]. In other studies, these patients demonstrated higher levels of anxiety and food restriction [ 40 ]; higher levels of depression, self-esteem and dietary restraint [ 36 ]; higher addictive personality traits [ 37 ]; higher weight preoccupation [ 39 ]; and higher levels of bulimic and eating disorder psychopathology [ 31 ].

Conclusions

From the research reviewed, it appears that there is a positive association between obsessive- compulsive personality traits in patients with AN who excessively exercise, yet the relationship with obsessive-compulsive disorder is less clear. Although it is known that excessive exercise is associated with poor treatment outcome in AN [ 28 , 29 ] the effects of obsessionality on treatment outcome are not yet known. Results of this paper indicate that obsessive-compulsive symptomatology and/or obsessive-compulsive personality traits contribute greater complexity to individual cases and may make these patients more resistant to treatment. Results support integrated interventions addressing the role of driven exercise in the context of obsessionality and obsessive compulsive symptoms where present, providing therapeutic interventions to alleviate emotional distress [ 31 ] and addressing characteristics such as perfectionism and behavioural rigidity [ 80 ]. The Loughborough Eating Disorders Activity Programme (LEAP) is an exemplar in this regard [ 81 ]. It is a manualised intervention which addresses driven exercise behaviours and beliefs using psycho-education and specific cognitive behavioural techniques to manage unhelpful beliefs and attitudes towards exercise, negative affective and compulsivity. Finally, future research into the relationship between driven exercise and obsessionality should utilise the most comprehensive and reliable clinical assessment tools, and address prognostic factors, treatment factors and specific interventions for patients with OCPD and/or OCD and driven exercise.

Authors’ information

SY submitted an alternate version of this manuscript as a requirement for the Doctor of Clinical Psychology/Master of Science thesis at University of Sydney. She is supervised by ST, PH and PR. PH, ST and PR are conducting a randomised controlled trial and evaluation of the Loughborough Eating Disorders Activity Programme (LEAP) referenced in this paper.

Touyz S: What kind of illness is anorexia nervosa? A clinical update. 2011, The Australian Psychological Society, Accessed online via http://www.psychology.org.au April, 2012

Google Scholar  

Davis C, Kaptein S, Kaplan AS, Olmsted MP, Woodside DB: Obsessionality in anorexia nervosa: the moderating influence of exercise. Psychosom Med. 1998, 60: 192-197.

Article   CAS   PubMed   Google Scholar  

Rothenberg A: Eating disorder as a modern obsessive-compulsive syndrome. Psychiatry. 1986, 49: 45-53.

CAS   PubMed   Google Scholar  

Jordan J, Joyce PR, Carter FA, Horn J, McIntosh VVW, Luty SE, McKenzie JM, Mulder RT, Bulik CM: Anxiety and psychoactive substance use disorder comorbidity in anorexia nervosa or depression. Int J Eat Disord. 2003, 34: 211-219. 10.1002/eat.10177.

Article   PubMed   Google Scholar  

O’Brien KM, Vincent NK: Psychiatric comorbidity in anorexia and bulimia nervosa: nature, prevalence, and causal relationships. Clin Psychol Rev. 2003, 23: 57-74. 10.1016/S0272-7358(02)00201-5.

Jacobi C, Haywood C, de Zwaan M, Kraemer HC, Agras WS: Coming to terms with risk factors for eating disorders: application of risk terminology and suggestions for a general taxonomy. Psychol Bull. 2004, 130: 19-65.

Halmi KA, Sunday SR, Klump KL, Strober M, Leckman JF, Fichter M, Kaplan A, Woodside B, Treasure J, Berrettini WH, Shabboat MA, Bulik CM, Kaye W: Obsessions and compulsions in anorexia nervosa subtypes. Int J Eat Disord. 2003, 33: 308-319. 10.1002/eat.10138.

Bastiani AM, Altemus M, Pigott T, Rubenstein C, Weltzin TE, Kaye W: Comparison of obsession and compulsion in patients with anorexia nervosa and obsessive–compulsive disorder. Biol Psychiatry. 1996, 39: 966-969. 10.1016/0006-3223(95)00306-1.

Hasler G, LaSalle-Ricci VH, Ronquillo JG, Crawley SA, Cochran LW, Kazuba D, Greenberg BD, Murphy DL: Obsessive–compulsive disorder symptom dimensions show specific relationships to psychiatric comorbidity. Psychiatry Res. 2005, 135: 121-132. 10.1016/j.psychres.2005.03.003.

Matsunaga H, Kaye WH, McConaha C, Plotnicov K, Pollice C, Rao R: Personality disorders among subjects recovered from eating disorders. Int J Eat Disord. 1999, 27: 353-357.

Article   Google Scholar  

Jarry JL, Vaccarino FJ: Eating disorder and obsessive-compulsive disorder: neurochemical and phenomenological commonalities. J Psychiatry Neurosci. 1996, 21: 36-48.

PubMed Central   CAS   PubMed   Google Scholar  

Gibbs NA, Oltmanns TF: The relation between obsessive–compulsive personality traits and subtypes of compulsive behavior. J Anxiety Disord. 1995, 9: 397-410. 10.1016/0887-6185(95)00020-O.

Rosen KV, Tallis F: Investigation into the relationship between personality traits and OCD. Behav Res Ther. 1995, 33: 445-450. 10.1016/0005-7967(94)00073-S.

Lilenfeld LR, Kaye WH, Greeno CG, Merikangas KR, Plotnicov K, Pollice C, Rao R, Strober M, Bulik CM, Nagy L: A controlled family study of anorexia nervosa and bulimia nervosa: psychiatric disorders in first-degree relatives and effects of proband comorbidity. Arch Gen Psychiatry. 1998, 55: 603-610. 10.1001/archpsyc.55.7.603.

Hsu LKG, Kaye W, Weltzin T: Are the eating disorders related to obsessive compulsive disorder?. Int J Eat Disord. 1993, 14: 305-318. 10.1002/1098-108X(199311)14:3<305::AID-EAT2260140309>3.0.CO;2-L.

Kaye WH, Weltzin TE, Hsu LKG, Bulik C: An open trial of fluoxetine in patients with anorexia nervosa. J Clin Psychiatry. 1991, 52: 464-471.

Keys A: The biology of human starvation. 1950, Minneapolis: University of Minnesota Press

Strober M: Personality and symptomatological features in young, nonchronic anorexia nervosa patients. J Psychosom Res. 1980, 24: 353-359. 10.1016/0022-3999(80)90027-6.

Casper R: Behavioral activation and lack of concern, core symptoms of anorexia nervosa?. Int J Eat Disord. 1998, 24: 381-393. 10.1002/(SICI)1098-108X(199812)24:4<381::AID-EAT5>3.0.CO;2-Q.

Davis C: Eating disorders and hyperactivity: a psychobiological perspective. [Review]. Can J Psychiatry. 1997, 42: 168-175.

Davis C, Kennedy SH, Ralevski E, Dionne M: The role of physical activity in the development and maintenance of eating disorders. Psychol Med. 1994, 24: 957-967. 10.1017/S0033291700029044.

Davis C, Katzman DK, Kaptein S, Kirsh C, Brewer H, Kalmbach K: The prevalence of high-level exercise in the eating disorders: etiological implications. Compr Psychiatry. 1997, 38: 321-326. 10.1016/S0010-440X(97)90927-5.

Epling WF, Pierce WD, Stefan L: A theory of activity based anorexia. Int J Eat Disord. 1983, 3: 7-46.

Boyd C, Abraham S, Luscombe G: Exercise behaviours and feelings in eating disorder and non-eating disorder groups. Eur Eat Disord Rev. 2007, 15: 112-118. 10.1002/erv.769.

Hausenblas HA, Cook BJ, Chittester NI: Can exercise treat eating disorders?. Exerc Sport Sci Rev. 2008, 36: 43-47. 10.1097/jes.0b013e31815e4040.

Bamber D, Cockerill IM, Rodger S, Carroll D: “It’s exercise or nothing”: a qualitative analysis of exercise dependence. Br J Sports Med. 2000, 34: 423-430. 10.1136/bjsm.34.6.423.

Article   PubMed Central   CAS   PubMed   Google Scholar  

Kaye WH, Gwirtsman HE, Obarzanek E, George DT: Relative importance of calorie intake needed to gain weight and level of physical activity in anorexia nervosa. Am J Clin Nutr. 1998, 47: 989-994.

Dalle Grave R, Calugi S, Marchesini G: Compulsive exercise to control shape or weight in eating disorders: prevalence, associated features and treatment outcome. Compr Psychiatry. 2008, 49: 346-352. 10.1016/j.comppsych.2007.12.007.

Carter JC, Blackmore E, Sutander-Pinnock K, Woodside DB: Relapse in anorexia nervosa: a survival analysis. Psychol Med. 2004, 34: 671-679. 10.1017/S0033291703001168.

Brewerton TD, Stellefson EJ, Hibbs N, Hodges EL, Cochrane CE: Comparison of eating disorder patients with and without compulsive exercising. Int J Eat Disord. 1995, 17: 413-416. 10.1002/1098-108X(199505)17:4<413::AID-EAT2260170414>3.0.CO;2-0.

Penas-Lledo E, Vaz Leal FJ, Waller G: Excessive exercise in anorexia nervosa and bulimia nervosa: relations to eating characteristics and general psychopathology. Int J Eat Disord. 2002, 31: 370-375. 10.1002/eat.10042.

Taranis L, Meyer C, Touyz S: Disordered Eating and Exercise: Development and Preliminary Validation of the Compulsive Exercise Test (CET). Eur Eat Disorders Rev. 2011, 19: 256-268. 10.1002/erv.1108.

Downs SH, Black N: The feasibility of creating a checklist for the assessment of the methodological quality both of randomized and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998, 52: 377-384. 10.1136/jech.52.6.377.

Ferro MA, Speechley KN: Depressive symptoms among mothers of children with epilepsy: a review of prevalence, associated factors, and impact on children. Epilepsia. 2009, 50: 2344-2354. 10.1111/j.1528-1167.2009.02276.x.

Anderluh M, Tchanturia K, Rabe- Hesketh S, Collier D, Treasure J: Lifetime course of eating disorders: design and validity testing of a new strategy to define the eating disorders phenotype. Psychol Med. 2009, 39: 105-114. 10.1017/S0033291708003292.

Bewell-Weiss CV, Carter JC: Predictors of excessive exercise in anorexia nervosa. Compr Psychiatry. 2010, 51: 566-571. 10.1016/j.comppsych.2010.03.002.

Davis C, Claridge G: The eating disorders as addiction: a psychobiological perspective. Addict Behav. 1998, 23: 463-475. 10.1016/S0306-4603(98)00009-4.

Davis C, Kaptein S: Anorexia nervosa with excessive exercise: a phenotype with close links to obsessive-compulsive disorder. Psychiatry Res. 2006, 142: 209-217. 10.1016/j.psychres.2005.11.006.

Davis C, Kennedy SH, Ralevski E, Dionne M, Brewer H, Neitzert C, Ratusny D: Obsessive compulsiveness and physical activity in anorexia nervosa and high-level exercising. J Psychosom Res. 1995, 39: 967-976. 10.1016/0022-3999(95)00064-X.

Holtkamp K, Hebebrand J, Herpertz-Dahlmann B: The contribution of anxiety and food restriction on physical activity levels in acute anorexia nervosa. Int J Eat Disord. 2004, 36: 163-171. 10.1002/eat.20035.

Naylor H, Mountford V, Brown G: Beliefs about excessive exercise in eating disorders: the role of obsessions and compulsions. Eur Eat Disord Rev. 2011, 19: 226-236. 10.1002/erv.1110.

Shroff H, Reba L, Thornton LM, Tozzi F, Klump KL, Berrettini WH: Features associated with excessive exercise in women with eating disorders. Int J Eat Disord. 2006, 39: 454-461. 10.1002/eat.20247.

Anderluh MB, Tchanturia K, Rabe-Hesketh S, Treasure J: Childhood obsessive-compulsive personality traits in adult women with eating disorders: defining a broader eating disorder phenotype. Am J Psychiatry. 2003, 160: 242-247. 10.1176/appi.ajp.160.2.242.

Fairburn CG, Cooper Z: The eating disorders examination. Binge eating: nature, assessment, and treatment. Edited by: Fairburn CG, Wilson GT. 1993, New York: The Guilford Press, 317-360. 12

Fairburn CG, Beglin SJ: Assessment of eating disorders: interview or self report questionnaire?. Int J Eat Disord. 1994, 16: 363-370.

Derogatis LR: Brief Symptom Inventory: administration, scoring, and procedures manual. 1993, Minneapolis: National Computer Systems

Beck AT, Steer RA, Brown GK: Beck depression inventory manual. 1996, New York: Guilford Press, 2

Rosenberg M: Conceiving the self. 1979, New York: Basic Books

Van Oppen P, Hoekstra RJ, Emmelkamp PMG: The structure of obsessive-compulsive symptoms. Behav Res Ther. 1995, 33: 15-23. 10.1016/0005-7967(94)E0010-G.

Garner DM, Olmsted MP: Eating disorder inventory manual. 1984, Florida: Psychological Assessment Resources

Eysenck HJ, Eysenck SBG: Manual of the Eysenck personality scales. 1991, London: Hodder & Stoughton

Lazare A, Klerman GL, Armour DJ: Oral, obsessive and hysterical personality patterns. J Psychiatry Res. 1970, 7: 275-290. 10.1016/0022-3956(70)90021-X.

Article   CAS   Google Scholar  

Hodgson RJ, Rachman S: Obsessional–compulsive complaints. Behav Res Ther. 1977, 15: 389-395. 10.1016/0005-7967(77)90042-0.

Frost R, Marten P, Lahart C, Rosenblate R: The dimensions of perfectionism. Cogn Ther Res. 1990, 14: 449-468. 10.1007/BF01172967.

Davis C, Brewer H, Ratusny D: Behavioral frequency and psychological commitment: necessary concepts in the study of excessive exercising. J Behav Med. 1993, 16: 611-628. 10.1007/BF00844722.

Franzoi SL, Shields SA: The body esteem scale: multidimensional structure and sex differences in a college population. J Personality Assess. 1984, 48: 173-178. 10.1207/s15327752jpa4802_12.

Janis IL, Field PB: A behavioral assessment of persuasibility: consistency of individual differences. Personality and persuasibility. Edited by: Jovland CI, Janis IL. 1959, New Haven: Yale University Press, 29-54.

Derogatis LR, Rickels K, Rock AF: The SCL-90 and the MMPI: a step in the validation of a new self-report scale. Br J Psychiatry. 1976, 128: 280-289. 10.1192/bjp.128.3.280. 7

Fichter MM, Herpertz S, Quadflieg N, Herpertz-Dahlmann B: Structured interview for anorexic and bulimic disorders for DSM-IV and ICD-10 (3rd Rev. ed.). Int J Eat Disord. 1998, 24: 227-249. 10.1002/(SICI)1098-108X(199811)24:3<227::AID-EAT1>3.0.CO;2-O.

Schmitz N, Hartkamp N, Kiuse J, Franke GH, Reister G, Tress W: The symptom check-list-90-R (SCL-90-R): a german validation study. Qual Life Res. 2000, 9: 185-193. 10.1023/A:1008931926181.

Obsessive Compulsive Cognitions Working Group: Psychometric validation of the obsessive belief questionnaire and interpretation of intrusions inventory– part 2: Factor analyses and testing of a brief version. Behav Res Ther. 2005, 43: 1527-1542.

Foa EB, Huppert JD, Leiberg S, Langner R, Kichic R, Hajcak G: The obsessive-compulsive inventory: development and validation of a short version. Psychol Assess. 2002, 14: 485-496.

Fairburn CG, Beglin SJ: Eating disorder examination questionnaire-6. Cognitive behaviour therapy and eating disorders. Edited by: Fairburn CG. 2008, New York: Guilford Press, 309-313.

Garner DM, Garfinkel PE: The eating attitudes test: an index of the symptoms of anorexia nervosa. Psychological Med. 1979, 9: 273-279. 10.1017/S0033291700030762.

Henderson M, Freeman CPL: A self-rating scale for bulimia- the BITE. Br JPsychiatry. 1987, 150: 18-24. 10.1192/bjp.150.1.18.

Derogatis LR: The SCL-90-R Administration, scoring and procedures: Manual-II for the Revised version (2nd Ed.). 1983, Towson: Clinical Psychometric Research

First M, Spitzer R, Gibbon M, Williams J: Structured clinical interview for DSM-IV axis I disorders, research version, patient edition. 1996, New York: Biometrics Research, New York State Psychiatric Institute

Cloninger CR, Przybeck TR, Svrakic DM, Wetzel RD: The temperament and character inventory (TCI): a guide to its development and use. 1994, St. Louis, MO: Center for Psychobiology of Personality, Washington University

Spielberger C, Gorsuch R, Luchene R: The state-trait anxiety inventory: test manual for form X. 1970, Palo Alto, CA: Consulting Psychologists Press

Goodman W, Price L, Rasmussen S, Mazure C, Fleischmann R, Hill C: The Yale–brown obsessive-compulsive scale (YBOCS): it’s development, use, and reliability. Arch Gen Psychiatry. 1989, 46: 1006-1011. 10.1001/archpsyc.1989.01810110048007.

Sunday SR, Halmi KA, Einhorn A: The Yale–brown–Cornell eating disorder scale: a new scale to assess eating disorder symptomatology. Int J Eat Dis. 1995, 18: 237-245. 10.1002/1098-108X(199511)18:3<237::AID-EAT2260180305>3.0.CO;2-1.

Cassin SE, von Ranson KM: Personality and eating disorders: a decade in review. Clin Psychol Rev. 2005, 25: 895-916. 10.1016/j.cpr.2005.04.012.

Richter MA, Cox BJ, Direnfeld DM: A comparison of three assessment instruments for obsessive–compulsive symptoms. J Behav Ther J Exp Psychol. 1994, 25: 143-147. 10.1016/0005-7916(94)90007-8.

Mond JM, Hay PJ, Rodgers B, Owen C: An update on the definition of “excessive exercise” in eating disorders research. Int J Eat Disord. 2006, 39: 147-153. 10.1002/eat.20214.

Davis C, Blackmore E, Katzman DK, Fox J: Female adolescents with Anorexia nervosa and their parents: a case control study of exercise attitudes and behaviors. Psychol Med. 2005, 35: 377-386. 10.1017/S0033291704003447.

Geller J, Cockell SJ, Goldner EM: Inhibited expression of negative emotions and the interpersonal orientations in anorexia nervosa. Int J Eat Disord. 2000, 28: 8-19. 10.1002/1098-108X(200007)28:1<8::AID-EAT2>3.0.CO;2-U.

Harris AM, Mcalpine DE, Shirbhate R, Manohar CU, Levine JA: Measurement of daily activity in restrictive type anorexia nervosa. Int J Eat Disord. 2008, 41: 280-283. 10.1002/eat.20486.

Article   PubMed Central   PubMed   Google Scholar  

Westerterp KR: Assessment of physical activity: a critical appraisal. Eur J Appl Physiol. 2009, 105: 823-828. 10.1007/s00421-009-1000-2.

Meyer C: Excessive exercise in the eating disorders: a need for less activity from patients and more from researchers. Eur Eat Disord Rev. 2008, 16: 81-83. 10.1002/erv.863.

Crane AM, Roberts ME, Treasure J: Are obsessive-compulsive personality traits associated with a poor outcome in anorexia nervosa? A systematic review of randomized controlled trials and naturalistic outcome studies. Int J Eat Disord. 2007, 40: 581-588. 10.1002/eat.20419.

The Loughborough eating disorders activity programme (LEAP) manual. http://store.lboro.ac.uk/browse/department.asp?compid=1&modid=1&deptid=233 ,

Download references

Acknowledgments

SY would like to acknowledge and sincerely thank PH, ST and PR for their assistance in preparing this manuscript, and for their supervision of her Master of Science thesis.

Author information

Authors and affiliations.

Clinical Psychology Unit, Mackie Building K01, School of Psychology, University of Sydney, Sydney, NSW, 2006, Australia

Sarah Young, Paul Rhodes & Stephen Touyz

School of Medicine, University of Western Sydney, Locked Bag 1797, Penrith, NSW, 2751, Australia

Phillipa Hay

School of Medicine, James Cook University, Townsville, North Queensland, Australia

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Sarah Young .

Additional information

Competing interests.

The authors declare that they have no competing interests.

Authors’ contributions

SY undertook the systematic review and with PH prepared this manuscript for journal submission. PH, ST and PR assisted with the editing of the manuscript and data interpretation. All authors read and approved the final manuscript.

Authors’ original submitted files for images

Below are the links to the authors’ original submitted files for images.

Authors’ original file for figure 1

Rights and permissions.

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Reprints and permissions

About this article

Cite this article.

Young, S., Rhodes, P., Touyz, S. et al. The relationship between obsessive-compulsive personality disorder traits, obsessive-compulsive disorder and excessive exercise in patients with anorexia nervosa: a systematic review. J Eat Disord 1 , 16 (2013). https://doi.org/10.1186/2050-2974-1-16

Download citation

Received : 02 October 2012

Accepted : 20 March 2013

Published : 02 May 2013

DOI : https://doi.org/10.1186/2050-2974-1-16

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Anorexia nervosa
• Obsessive-compulsive disorder
• Obsessive-compulsive personality

Journal of Eating Disorders

ISSN: 2050-2974

• General enquiries: [email protected]

Comorbidity of obsessive-compulsive disorder and anorexia nervosa – diagnostic difficulties: a case study of a 14-year old girl

• Related Documents

P.406 Deep brain stimulation in treating anorexia nervosa and comorbid obsessive compulsive disorder: a 12 months follow-up case study

Constructivist strategies in cognitive-behavioral therapy for managing obsessive-compulsive disorder: a case study, acceptance and commitment therapy in obsessive–compulsive disorder: a case study.

Recent years have witnessed an increased interest in the use of “third-wave” psychotherapies in treating psychiatric disorders. These newer therapies are fundamentally different from the existing techniques such as cognitive behavioral therapy in terms of their guiding principles and processes of change. Acceptance and commitment therapy (ACT) is the most prominent among these “third wave” psychotherapies. However, there have not been any reports from India, thus far, that have studied the use of ACT in treating obsessive–compulsive disorder (OCD). We describe a case of OCD that was successfully treated with eight sessions of ACT, with the results being maintained over a one-month follow-up period. Postintervention tests revealed a significant decrease in obsessive–compulsive symptoms and an associated increase in psychological flexibility. This case study highlights the possible utility of ACT as a therapeutic intervention in OCD, especially when combined with pharmacotherapy.

Cognitive Remediation Therapy Does Not Enhance Treatment Effect in Obsessive-Compulsive Disorder and Anorexia Nervosa: A Randomized Controlled Trial

Anorexia nervosa, major depression, and obsessive-compulsive disorder in a down's syndrome patient, genetic variability in the serotoninergic system and age of onset in anorexia nervosa and obsessive-compulsive disorder, assessment and treatment of comorbid anorexia nervosa and obsessive–compulsive disorder, predicting eating disorder and anxiety symptoms using anorexia nervosa and obsessive-compulsive disorder polygenic scores.

Clinical, epidemiological, and genetic findings support an overlap between eating disorders, obsessive-compulsive disorder (OCD), and anxiety symptoms. However, little research has examined the role of genetic factors in the expression of eating disorders and OCD/anxiety phenotypes. We examined whether the anorexia nervosa (AN), OCD, or AN/OCD transdiagnostic polygenic scores (PGS) predict eating disorders, OCD, and anxiety symptoms in a large population-based developmental cohort. Using summary statistics files from the Psychiatric Genomics Consortium Freeze 2 AN and Freeze 1 OCD GWAS, we first conducted an AN/OCD transdiagnostic GWAS meta-analysis and then calculated PGS for AN, OCD, and AN/OCD in participants from the Avon Longitudinal Study of Parents and Children with available genetic and phenotype data on eating disorder, OCD, and anxiety diagnoses and symptoms (sample size 3,212-5,369 per phenotype). We observed sex differences in the PGS prediction of eating disorder, OCD, and anxiety-related phenotypes, with AN genetic risk manifesting at an earlier age and playing a more prominent role in eating disorder phenotypes in boys than in girls. Compulsive exercise was the only phenotype predicted by all three PGS (e.g., PAN(boys)=0.0141 at age 14; POCD(girls)=0.0070 at age 16; PAN/OCD(all)=0.0297 at age 14). Our results suggest that earlier detection of eating disorder, OCD, and anxiety-related symptoms could be made possible by including measurement of genetic risk for these psychiatric conditions while being mindful of sex differences.

A Case Study of Obsessive-Compulsive Disorder: Some Diagnostic Considerations

Schizophrenia with obsessive compulsive symptoms: a case report.

Obsessive-compulsive disorder/ symptoms may be co-morbid in schizophrenia. The clinical impact of this co-morbidity is poor response to anti-psychotic medications. We present a case of 35 yr old female who presented with symptoms suggestive of schizophrenia and later co-morbid obsessive symptom responded well to addition of fluoxetine to antipsychotics. This case study reveals that the identification and treatment of OCD in schizophrenia is very crucial for optimistic outcome.

Export Citation Format

Share document.

• Skip to Main Content
• ePortfolios Directory

Ashley Kimble

Professional exhibits.

• Practical Experiences
• Certifications / Awards
• Reflections
• Case Study on Stroke
• Case Study on TBI
• Group Initiative Project
• Activity Notebook
• Case Study on OCD
• Case Study on Anorexia Nervosa
• Activity and Task Analysis
• Final Report
• Assessments
• Mindfulness
• Client needs and outcomes
• Marketing Campaign
• Comprehensive Program Plan

      Megan is a 17-year old female, who on admission to the residential eating disorder program, is 5’6” tall and weighs 87 pounds. She is a senior in high school and is on the honor roll. She is class president and an athlete on the volleyball and track teams. She wears oversized clothes and her parents report that she has become obsessed with her weight. Despite losing 20 pounds in the first few months, she still considers herself to be fat. Megan and her parents constantly fight over the amount she eats at meal times. She often refuses to come to the table to eat dinner. Her parents report trying everything to get Megan to eat including fixing her favorite meals, taking her out to her favorite restaurants, nagging, coaxing, and eventually fighting. She eats little at home; when her mother confronts her on how much she has eaten, Megan states she ate a big lunch at school. Mom does not believe this and another argument usually starts.

      Megan’s parents report they are at “their wits end”; they do not understand what has happened to their daughter. She has always been bright and eager to please. She is an “A” student and a gifted athlete. She has received an athletic scholarship to college for track. Her parents started to notice changes in Megan over the last six months. First, she started limiting her food intake, eating less at meals and eliminated snacks. Her reason was she needed to keep her weight down. She began eating only low calorie foods because she thought she was fat. Megan began calorie counting and mom noticed that instead of eating most of what was on her plate, she just pushed the food around and actually consumed very little. The food groups must not touch on her plate and she spends most of the time cutting the food into tiny, uniform pieces rather than eat the food. When mom points out these behaviors arguments begin, often resulting in Megan leaving the table in tears and retreating to her room. Now it is a chore to get her to come to the table at meal times.

      Both parents also report that Megan began running longer distances and added runs in addition to practice. They also think that she is exercising in her room as they hear noises associated with jumping. Megan spends most of her time alone. This is very different from past behaviors where Megan spent most of her time alone. This is very different from past behaviors where Megan spent most of her time with two friends. She says she is too busy trying to keep her grades up and perform well in track. She believes she must work harder so that she succeeds when she goes to college next year. It is important that she continues to do well so that she does not lose her scholarship.

      Megan is very angry about being in the eating disorder program. She wonders why everyone insists she has a problem when there is nothing wrong. The most puzzling aspect to Megan is that everyone tells her she is too thin when it is obvious that she is fat. She believes that being in the program is a waste of her time. When asked what she thinks is happening, Megan states that her parents are trying to control her life and they do not want her to away to college next year. They are on her “case” all the time and will not leave her alone. Megan states she needs to lose weight not gain weight. Megan is restricting her intake of food to fewer than 1000 calories a day. She believes this is the only way for her to lose weight. She runs between 2 ½ to 3 hours a day, but this is spread throughout the day. She states it is necessary to put in this time as she runs track. She also puts pressure on herself to maintain her grades. When pressed about her performance in school, Megan reluctantly admits that her grades are slipping; she is having difficulty concentrating in school and studying. She states she is just tired, has difficulty motivating herself at times but she will just have to work harder to catch up. She thinks that being in this program (treatment) is causing her to fall further behind in her schoolwork.

      Megan has two younger brothers. She says they get along for the most part but hey have been teasing her about her weight picking up on the arguments she and her parents have had. She says she fights with her parents because they will not leave her alone. She got along fine with her parents until they started nagging her about her food and weight. The reason they got along before was because Megan did what they wanted. Now she does what she wants and they cannot deal with that. She cannot wait to get away from home so that she can control her own life.

      Megan says she has lots of friends. She used to spend time with her two best friends but she stopped spending time with them because they began to nag her about her eating. She does not have a boyfriend although she has dated a few guys. She now prefers to spend time by herself. She has stopped most of the social activities that she used to do. When asked why this has changed, she stated that she must concentrate on grades and running to keep her scholarship.

       Megan has not had her period for about 3 to 4 months, she is not sure when her last cycle occurred. She is not concerned about this. Her greatest worry is gaining weight. She is afraid that if she starts to eat certain foods, she will not stop eating. She will not go into a grocery store for fear of buying foods that are “off limits” to her. She does not like to go out to eat because she does not know what is in the food or how it is prepared. She does not enjoy shopping for clothes anymore as she cannot wear the popular clothes because she is too fat. She must focus on her exercising so that she can again fit into nice clothes. The exercising also keeps her mind off of food and gives her a sense of relief that she can control her weight.

What problems do you identify for Megan?

• Considers herself to be fat still after losing 20 pounds in the first few months
• Lies to her family about how much food she is consuming
• Spends most of her time alone now
• Thinks parents are trying to control her life
• Plans the treatment program to be the reasoning for her falling behind in classes
• Exercises more than regularly

What are some strengths for Megan?

• She is very athletic
• She knows nutrition well but needs to learn how to eat appropriately
• She is tremendously smart and continously being concerned about her grades
• Has scholarships

What goals would you set for Megan?

• Client should not be able to exercise other than when her track practices are
• Client must see a nutritionist weekly
• Client needs to go grocery shopping with her mom
• Client participates in outings with her friends

What RTH interventions and strategies would you recommend for Megan?

• Group Therapy sessions with other Anorexia clients

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List

An examination of autism spectrum traits in adolescents with anorexia nervosa and their parents

Charlotte rhind.

Department of Psychological Medicine, Section of Eating Disorders, King’s College London, Institute of Psychiatry, Psychology and Neuroscience, PO59 103 Denmark Hill, London, SE5 8AF UK

Elena Bonfioli

Department of Public Health and Community Medicine, University of Verona, P.le L.A. Scuro 10, Verona, 37134 Italy

Rebecca Hibbs

Elizabeth goddard, pamela macdonald, simon gowers.

University of Liverpool, Psychological Sciences, Waterhouse Building, Block B, Brownlow Street, Liverpool, L69 3GL UK

Ulrike Schmidt

Kate tchanturia.

Ilia State University, Kakutsa Cholokashvili Ave 3/5, Tbilisi, 0162 Georgia

Nadia Micali

Institute of Child Health, Behavioral and Brain Sciences Unit, University College London, 30 Guilford Street, London, WC1N 1EH UK

Janet Treasure

There may be a link between anorexia nervosa and autism spectrum disorders. The aims of this study were to examine whether adolescents with anorexia nervosa have autism spectrum and/or obsessive-compulsive traits, how many would meet diagnostic criteria for autism spectrum disorder, and whether these traits are shared by parents.

A total of 150 adolescents receiving outpatient treatment for anorexia nervosa or subthreshold anorexia nervosa and their parents completed the autism spectrum disorder and eating disorder sections of the Development and Well-being Assessment. Patients also completed the Children Yale-Brown Obsessive-Compulsive Scale and other measures of psychiatric morbidity, and parents completed the short Autism Quotient and Obsessive-Compulsive Inventory Revised.

Adolescents with anorexia nervosa had a below average social aptitude (19% below cut-off) and high levels of peer relationship problems (39% above cut-off) and obsessive-compulsive symptoms (56% above cut-off). Six cases (4%, all females) were assigned a possible (n = 5) or definite (n = 1) diagnosis of autism spectrum disorder. Parental levels of autism spectrum and obsessive-compulsive traits were within the normal range.

Conclusions

This study suggests that adolescents with anorexia nervosa have elevated levels of autism spectrum traits, obsessive-compulsive symptoms, and a small proportion fulfil diagnostic criteria for a probable autism spectrum disorder. These traits did not appear to be familial. This comorbidity has been associated with a poorer prognosis. Therefore, adaptation of treatment for this subgroup may be warranted.

Trial registration

Controlled-trials.com: ISRCTN83003225 . Registered on 29 September 2011.

An association between low empathy during development and the later development of an eating disorder (ED) was suggested by Gillberg in 1992 [ 1 ]. He proposed that individuals with autism spectrum disorders (ASD) and those with anorexia nervosa (AN) may share traits, some of which might be familial [ 1 ]. Evidence summarized in recent reviews provides support for this hypothesis, suggesting that there may be a shared liability between AN and ASD [ 2 – 4 ]. For example, both disorders have a similar profile of neuropsychological function (problems with set shifting, central coherence, and social cognition) and behavioral traits such as social problems, and obsessive-compulsive features such as rigidity and attention to detail [ 2 – 4 ], although the neuropsychological profile of adolescents with AN is less clear (for an example see Lang et al . [ 5 ]).

Several studies have used the autism quotient (AQ), a self-report measure of autism spectrum traits, in people with AN and have found higher than normal scores [ 6 , 7 ]. A study using the AQ and measures of systemizing and empathizing traits concluded that over 40% of adolescents with AN fulfilled the criteria for the broad autistic phenotype [ 8 ]. Another study found that 26% of adults with AN scored above the cut-off score on the short AQ [ 9 ]. In a large population study using parent report, 23% of children with restrictive eating problems also screened positive for ASD [ 10 ]. These studies suggest that there are shared traits between AN and ASD.

One problem in establishing the association between these conditions is that it can be difficult to make the diagnosis of ASD in women. Their clinical presentation differs from that typically seen in men, as summarized in a recent review [ 11 ]. Parents endorse different items for girls with ASD (such as ‘avoids demands’ , ‘very determined’ , and ‘careless with physical appearance and dress’) using a scale adapted to capture the female phenotype of ASD [ 12 ]. Furthermore, females present with more lifetime sensory problems [ 13 ]. It is thought that females with autism spectrum traits may be more likely to focus on eating or shape and weight issues as a topic of special interest.

People with EDs and their family members have higher levels of obsessive-compulsive personality traits [ 14 , 15 ]. Behavioral traits, such as attention to detail and rigidity, are part of this personality profile and are common to those with EDs and ASD [ 2 – 4 ]. For example, the perceptual style of weak central coherence characterized by precedence for detail processing and/or difficulties with integrating global information is present in all three disorders [ 16 – 18 ]. A compulsivity phenotype may account for some of the common variance between these co-morbid conditions [ 19 ].

The aims of this study were to examine this dimensional approach to diagnosis by assessing whether adolescents with AN have autism spectrum and obsessive-compulsive traits, to establish the prevalence of ASD amongst this patient group, and whether these traits are shared by parents. It was hypothesized that (1) adolescents with AN would have higher levels of autism spectrum (poorer social aptitude skills and greater peer difficulties) and obsessive-compulsive traits, relative to population norms; (2) a higher proportion of adolescents with AN would fulfil diagnostic criteria for ASD than female healthy population norms, using the Development And Well-being Assessment (DAWBA) [ 20 ]; and (3) parents of adolescents with AN would have higher levels of autism spectrum and obsessive-compulsive traits, relative to population norms.

Participants

Adolescents newly referred for outpatient treatment with a primary diagnosis of AN or ED Not Otherwise Specified AN subtype (EDNOS-AN) and their parents completed a battery of assessments as part of a randomized controlled trial (Experienced Carers Helping Others (ECHO, trial registration: ISRCTN83003225)). Participants were recruited from 38 National Health Service (NHS) England outpatient services, providing an ecologically relevant sample representative of current United Kingdom practice. ED diagnoses were made by a clinician at the local recruitment site, according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria [ 21 ]. An age range of 13 to 21 years was chosen to represent an adolescent sample; up until brain development comes to completion (early twenties) [ 22 ] and usually whilst in full-time education. This is also consistent with previous similar adolescent trials [ 23 ]. Main ethics approval was granted by the Northwick Park Hospital Ethics Committee (approval number: 11/H0724/4) and site-specific ethics and governance approval granted on all participating sites (please see Acknowledgements). Written assent was collected for all patients and informed consent from their parents or guardians and all other participating carers was collected prior to entering the study in accordance with ethical guidelines. The methodology is described in detail elsewhere [ 24 ]. Only participants who completed the DAWBA and their parents were included in the present study. The final sample consisted of 150 adolescents (92% of total recruited) receiving treatment for AN (75%) or EDNOS-AN (25%) and their parents (n = 207). No differences were found between the participants included in the present study and the 163 patients and 224 parents recruited on clinical (body mass index (BMI), lowest BMI, and illness duration) and demographic variables (gender, employment, and marital status) with the exception of parental age which was greater in the sample included (data not shown).

Patient measures

Standard demographic and clinical information were completed as self-report by patients (validated by clinicians) and their parents.

The developmental and well-being assessment

The DAWBA [ 20 ] is a well-validated and extensively used measure in epidemiological studies that is designed to generate a DSM-IV and an International Statistical Classification of Diseases and Related Health Problems (ICD-10) psychiatric diagnosis for childhood and adolescent psychiatric disorders. The ASD section is used as a diagnostic measure in population-based prevalence studies of ASD [ 25 , 26 ]. In the present study, parents (informants) and patients (self-report) complete the ASD and ED sections of the computerized DAWBA which includes interview questions (each with screening questions) and skip rules. Parents report on their child’s development (language, routines, play, and social ability) and complete the Social Aptitudes Scale (SAS) [ 27 ], both designed to capture ‘traits’ rather than ‘state’ effects. The SAS is designed to tap the sorts of social aptitudes that require a good ability to read social and emotional cues rapidly in complex situations in order to guide socially skilled behaviour. Parents rate their child from ‘a lot worse than average’ to ‘a lot better than average’ , relative to other children of the same age, across 10 items. Low scores index a substantially raised risk of ASDs. The SAS has been well-validated and demonstrated good psychometric properties: data from a large epidemiological study of young people in the United Kingdom produced a mean score of 24.57 (SD = 6.26, n = 7768) with higher scores for females (mean = 25.33, SD = 6.14, n = 3764). A cut-off score of 16 or less is associated with good screening properties for the diagnosis of ASD [ 27 ]. Age-transformed aptitude scores with a mean of 50 and standard deviation of 10 have been developed [ 27 ]. Cronbach’s α coefficient (α) for responses to the SAS in the present study was 0.90.

The DAWBA generates six diagnostic probability bands (ranging from <0.1 to >70% likelihood) and a summary of structured and open-ended interview data, triangulated across informants by a trained experienced clinician (NM), who assigned a diagnosis (‘yes’ , ‘possible’ , or ‘no’) according to DSM-IV and ICD-10 criteria.

Parents and the individuals themselves also completed the Strengths and Difficulties Questionnaire (SDQ) [ 28 ] which consists of 25 items that assess behaviour problems, hyperactivity, emotional symptoms, peer problems, and pro-social skills. The sum of the first four subscale scores forms a total difficulties score, with higher scores indicating greater difficulties. Ratings of child distress and the impact of difficulties on social capital form a total impact score. Social skills can be inferred from the pro-social and peer relationship subscales. Good psychometric properties are reported for the SDQ. Normative data from a large epidemiological study [ 29 ] are available online with cut-off points; specifically, peer difficulties scores of 0 to 2 may be classified as normal, a score of 3 as ‘borderline’ , and scores of 4 to 10 as ‘abnormal’. In the current study, Cronbach’s α for responses to the SDQ symptom domains was 0.83 (informant) and 0.82 (self-report).

The children’s Yale-Brown obsessive-compulsive scale

Obsessive-compulsive traits in patients were assessed using the self-report Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS-SR) [ 30 ]. Higher scores indicate higher symptom severity (score range 0 to 40) and scores of 16 and over are used as a cut-off for clinically significant obsessive-compulsive disorder. Cronbach’s α for responses to the CY-BOCS-SR in the current study was 0.71.

The short evaluation of eating disorders

The Short Evaluation of EDs (SEED) [ 31 ] was completed by self-report to assess ED symptom severity. Responses are scored using an algorithm including weight and key symptoms and computed a total AN and Bulimia Nervosa (BN) symptom severity index (score range 0 to 3; higher score indicating severity). Cronbach’s α for the SEED in this study was 0.72.

Clinical impairment assessment 3.0

Psychosocial impairments related to the ED features over the past 28 days were also assessed using the Clinical Impairment Assessment (CIA) [ 32 ]. A global score is calculated with higher scores indicating greater severity of impairment. Cronbach’s α for the CIA in this study was 0.94.

The depression, stress and anxiety scale

The Depression, Stress and Anxiety Scale (DASS-21) [ 33 ] was used as a self-report measure of current mood state. Cronbach’s α for the DASS-21 was 0.94.

Parent measures

The short autism quotient.

Autism spectrum traits in parents were assessed using the Short Autism Quotient (AQ-10) [ 34 ]. Healthy adults produced a mean score of 2.77 (SD = 2.00) and a cut-off point of 6 is indicative of ASD [ 34 ]. Cronbach’s α for the AQ-10 in this study was 0.56.

The obsessive-compulsive inventory

Obsessive-compulsive traits in parents were measured using the Obsessive-Compulsive Inventory (OCI-R) [ 35 ]. A cut-off point of 21 is indicative of clinically significant obsessive-compulsive disorder. Cronbach’s α for the OCI-R in this study was 0.88.

Data analysis

Data were analyzed using IBM SPSS Statistics for Windows, Version 21.0: Armonk, New York. Descriptive statistics summarized means and standard deviations for patient and parent scores on all measures. Independent samples t-tests were used for group comparisons: social aptitude scores in present study sample versus population mean; patients who did versus did not receive a diagnosis for ASD; and mothers versus fathers. Cohen’s d was used to calculate effect sizes. Spearman’s correlations were used to measure associations between patients autism spectrum and obsessive-compulsive traits, and their current ED clinical characteristics, and parental traits, applying a Bonferroni-corrected α (0.05 out of 13, α = 0.004) to correct for multiple comparisons.

The patient sample was 91% female, 96% Caucasian, and 91% were living with their parents. The age ranged from 13 to 21 years (mean = 16.90, SD = 2.13) and 83.6% were within three years of illness onset. The majority of patients (69%) had received no prior treatment for their ED. One patient in the sample reported having received a diagnosis of ASD. Other clinical information is displayed in Table  1 . The mother (mean age = 48 years, SD = 4.82) was involved in the study for 95% of patients and the father for 42% (mean age = 51 years, SD = 5.06).

Sociodemographic and clinical characteristics

a Age standardized weight-for-height (participants aged <20 years (n = 126) only are reported), according to Great Ormond Street Hospital for Children criteria.

b Clinical rating using the DAWBA (DSM-IV and ICD-10 criteria).

Abbreviations: AN, Anorexia Nervosa; ASD, Autism spectrum disorder; BMI, Body Mass Index; BN, Bulimia Nervosa; DAWBA, Development and Well-being Assessment; ED, Eating Disorder; EDNOS, Eating Disorder Not Otherwise Specified.

Psychometric assessment of adolescents with anorexia nervosa

Social aptitude scores (mean = 22.87, SD = 8.16) were lower than the healthy population norm (see legend, Table  2 ; t = 3.03, p  = 0.002, d = -0.23), particularly for females (mean = 22.71, SD = 8.35; t = 4.51, p <0.001, d = -0.36). Scores fell within the clinically significant range for 18.8% of patients. They were not significantly correlated with clinical characteristics (BMI, illness duration, AN symptom severity, BN symptom severity, ED clinical impairment, depression, anxiety, or stress scores; data not shown).

Patient psychiatric symptomatology and comorbidity

a Lower scores indicate poor social aptitude (cut-off score 16 or less). British (age 11 to 14 years) healthy population mean = 24.57 (SD = 6.26), females only mean = 25.33 (SD = 6.14), males only mean = 23.81 (SD = 6.38). SAS Age-Transformed-score mean = 50 (SD = 10) [ 27 ].

b British (age 11 to 14 years) healthy population informant-rated mean = 1.5 (SD = 1.7), self-report mean = 1.5 (SD = 1.4) [ 29 ].

c British (age 11 to 14 years) healthy population informant-rated mean = 8.6 (SD = 1.6), self-report mean = 8.0 (SD = 1.7) [ 29 ].

d British (age 11 to 14 years) healthy population females (F) and males (M) selecting those with no intellectual disability ASD band <0.1% = 98.3% (F), 95.7% (M); ASD band approximately 3% = 1.2% (F), 2.1% (M); ASD band approximately 15% = 0.3% (F), 1.4% (M); ASD band approximately 50% = 0.2% (F), 0.4% (M).

e Valid percentages presented.

e Clinical rating using the DAWBA (DSM-IV and ICD-10 criteria).

Abbreviations: SAS, Social Aptitude Scale; SDQ, Strengths and Difficulties Questionnaire; ASD, Autism Spectrum Disorder.

For both categories of rater (informant (I) and self-report (SR)) completing the SDQ, the highest levels of difficulties relative to norms were in the emotional (I: d = 2.07, SR: d = 1.73) and peer domains (I: d = 0.76, SR: d = 0.94). Peer difficulties were ‘abnormal’ for 38.5% of patients, and ‘borderline’ for a further 12.9%. Informants only reported lower than average levels of pro-social skills (I: d = -0.75, SR: d = -0.05), particularly for females (I: d = -0.89, SR: d = -0.37). The individuals themselves reported higher than average levels of hyperactivity (SR: d = 0.62) and a smaller effect was reported by informants (I: d = 0.32). Informants rated a moderate level of conduct problems (I: d = 0.52, SR: d = 0.05).

Scores for obsessive-compulsive symptoms (CY-BOCS-SR) were within the clinically significant range for obsessive-compulsive disorder in 56.4% of the sample. Scores were significantly correlated with duration of illness (Spearman’s correlation coefficient ( r s ) = 0.26, p <0.001), BN symptom severity ( r s  = 0.34, p <0.001), ED clinical impairment ( r s  = 0.51, p <0.001), depression ( r s  = 0.42, p <0.001) and anxiety ( r s  = 0.45, p <0.001), but not with BMI, lowest BMI or AN symptom severity.

Diagnostic assessment of autism spectrum disorder

Compared with normative data, more AN females were assigned to the higher diagnostic probability bands of the DAWBA (10.9% AN versus 1.2% norms at level 2 (>3% likelihood of ASD) and 2.5% AN versus 0.3% norms at level 3 (>15% likelihood of ASD)).

Six individuals (4%, all female) were assigned a possible (n = 5) or definite (n = 1) diagnosis of ASD by the clinical rater. Clinical and psychometric features of these cases are displayed in Table  2 . Informant-rated scores for total difficulties (d = 0.95) and impact (d = 1.47) were higher for this subgroup.

Parental autism spectrum and obsessive-compulsive traits

Levels of autism spectrum and obsessive-compulsive traits in parents of adolescents with AN were within the normal range (Table  3 ). Only 2.2% of parents (n = 2 (3.1%) fathers, n = 2 (1.4%) mothers) scored within the clinically significant range suggestive of ASD. Fathers produced higher scores than mothers (t = -3.32, p  = 0.001, d = 0.51). Scores for obsessive-compulsive traits (OCI-R) were within the clinically significant range for 7.9% of parents.

Parental traits

Means and SD displayed; Abbreviations: ASD, Autism spectrum disorder; AQ-10, Autism Quotient; OCI-R, the Obsessive-Compulsive Inventory Revised.

There were no significant differences in autism spectrum traits (AQ-10) between parents of those assigned an ASD diagnosis compared with those who were not.

Correlations between autism spectrum and obsessive-compulsive traits

Table  4 presents the correlations between autism spectrum (social aptitude and SDQ peer problems, and pro-social behaviors) and obsessive-compulsive traits (CY-BOCS-SR) in patients and in mothers and fathers (AQ-10 and OCI-R). Patient autism spectrum traits (social aptitude, peer difficulties, and pro-social behaviors) and obsessive-compulsive traits were not significantly correlated. Parental autism spectrum (AQ-10) and obsessive-compulsive traits (OCI-R) were significantly correlated for mothers only. Parental traits were not correlated with autism spectrum or obsessive-compulsive scores in patients.

Correlations between autism spectrum disorder and obsessive - compulsive disorder traits in female patients and their parents

Spearman’s correlation coefficient ( r s ) applying a Bonferroni-corrected alpha (α = 0.004); Abbreviations: AQ-10, Autism Quotient; ASD, Autism spectrum disorder; CY-BOCS-SR, Children’s Yale-Brown Obsessions and Compulsions Symptom Scale Revised; OCD, Obsessive-compulsive disorder; OCI-R, the Obsessive-Compulsive Inventory Revised.

a Strength and Difficulties Questionnaire by self-report.

b Strength and Difficulties Questionnaire by informant.

* p <0.003, ** p <0.001.

The first aim of this study was to examine whether adolescents with AN have traits suggestive of ASD. We confirmed our first hypothesis in that we found that poor social aptitude skills and peer difficulties were more prevalent in the AN patients than in healthy population norms. We also found high co-morbid obsessive-compulsive traits in the patient group. We found that six (4%) patients met the diagnostic criteria for a possible or definite ASD. However, we failed to confirm our hypothesis that the parents of the patient group would have higher than normal levels of autism spectrum and obsessive-compulsive traits.

The prevalence of autism spectrum traits (low social aptitude (18.8%) and peer difficulties) is similar to the approximate 20% of the cohort of adolescent cases of AN who were thought to have social communication difficulties reported by Gillberg [ 1 ] and the 23% of children with restrictive eating problems who also screened positive for ASD [ 10 ]. It is lower than the 40% of adolescents fulfilling the Baron Cohen's criteria for the broad autistic phenotype [ 8 ]. The different populations, screening, and diagnostic procedures used in these studies may account for this variance.

The prevalence of diagnostically defined cases (4%) is lower than the proportion (23%) of adult patients with a severe and enduring ED who were considered to have ASD [ 36 ]. In part this may relate to the use of the DAWBA as a developmentally based diagnostic measure; however, given the poor prognosis of this group [ 37 ], it might be expected that a greater proportion of cases with ASD will be found in cohorts with a severe and enduring illness.

The six individuals with possible and definite ASD had a similar clinical profile to the group as a whole. However, informant ratings suggested that this subgroup had greater overall difficulties. However, given the small number, group comparisons are underpowered and these descriptors are therefore unreliable.

The problems in social functioning are consistent with the previous literature. Patients with EDs particularly those with AN retrospectively report social difficulties in childhood [ 38 ]. In a longitudinal study, social problems at age eight were strongly predictive of ED onset at age 14 [ 39 ]. Furthermore, a recent systematic review has documented the wide range of difficulties within the social cognition domain [ 40 ]. Although there may be ‘state’ effects of AN on neuropsychological functioning, the lack of association between social aptitude and current AN features is more indicative of a trait level of disturbance. The level of other forms of comorbidity in this group (obsessive-compulsive disorder traits, negative affect and some Attention Deficit/ Hyperactivity Disorder symptoms) is similar to that in the literature [ 41 – 43 ].

We did not find that the parents of patients with EDs had high levels of autism spectrum traits themselves. Parents of people with ASD have been found to have high autism quotient scores [ 44 , 45 ], mainly in the social and communication domains [ 46 , 47 ], suggesting that there is a broad familial ASD phenotype. However, this finding is less robust in mothers of people with ASD [ 48 ]. The small number of cases and the different instruments used makes the interpretation of possible cross-generational traits versus possible ‘state’ effects of AN difficult.

Strengths and limitations

One of the strengths of this study was the use of the DAWBA as an assessment measure that has been widely employed in epidemiological studies of child and adolescent psychiatry, with healthy population norms available for comparison. Furthermore, because the DAWBA is framed developmentally and collects self-report and informant perspectives, it is less reliant on current symptoms or impairment (‘state’ effects of AN). Another strength of this study is the inclusion of both child and parent data. Nevertheless, several limitations must be noted; we used instruments that measured obsessive-compulsive disorder behaviors and it would have been preferable to have included instruments to measure traits associated with compulsivity, an over-controlled temperament, and obsessive-compulsive personality. Additionally, the internal consistency of the AQ-10 was poor and caution must be taken when interpreting these results. It would have been preferable to have also screened the participants themselves with the AQ-10. The possibility that the DAWBA is less diagnostically sensitive than an in-depth face-to-face clinician examination must also be considered. Given that the DAWBA assigned fewer AN and overall ED diagnoses in a sample of clinically diagnosed and treatment-seeking AN and EDNOS-AN patients, it is possible that the DAWBA provides a relatively conservative diagnostic tool. Furthermore, the patient previously diagnosed with ASD prior to entering the study was assigned a ‘probable’ (rather than ‘definite’) diagnosis using the DAWBA in the present study. It is therefore possible that the prevalence of ASD in AN may be higher than that reported in this study. Finally, the data presented do not represent all treatment-seeking patients, but only the group who consented to be involved in a study that involves their parents. It is possible that the sample is therefore biased towards patients with parents who were more actively involved in their child’s care.

Clinical implications

We have found that a small number of adolescent AN cases are possibly comorbid with ASD. We have also found evidence of transdiagnostic traits such as social communication and emotional problems. These may be associated with ASD, the over-controlled temperament [ 49 ], and obsessive-compulsive personality [ 50 ] in adolescents with EDs. Treatment adaptations to target these difficulties may be beneficial.

Approximately one fifth of adolescents with AN have obsessive-compulsive traits and problems in peer relationships and social functioning. A much smaller proportion (4%) fulfil the diagnostic criteria for a probable ASD. It will be of interest in the future to establish the prognosis of this subgroup and whether these traits moderate the response to standard treatment, as suggested by Crane et al . [ 51 ].

Acknowledgements

We thank Professor Robert Goodman for his guidance and support throughout this study.

This manuscript presents independent research funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit program (PB-PG-0609-19025). The views expressed in this article are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. CR acknowledges scholarship funding from the Psychiatry Research Trust (PRT Grant Reference: 29). This study was supported by the United Kingdom Clinical Research Collaboration-registered King’s Clinical Trials Unit at King’s Health Partners, which is part funded by the NIHR Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and King’s College London and the NIHR Evaluation, Trials and Studies Coordinating Centre.

We also thank the Principal Investigators, who were involved in the recruitment of participants at the outpatient sites, listed alongside the site-specific ethical bodies who approved the study as follows: S Clark-Stone, 2gether NHS Foundation Trust; W Clarke, Anuerin Bevan Local Health Board; D Robertson, Birmingham and Solihull Mental Health NHS Foundation Trust; N Dawson, Bradford District Care Trust; C Schrieber-Kounine, Avon and Wiltshire Mental Health Partnership NHS Trust; J Shapleske, Cambridgeshire and Peterborough NHS Foundation Trust; J Whittaker, Central Manchester University Hospitals NHS Foundation Trust; A Jones, Cornwall Partnership NHS Trust; K Goss, Coventry and Warwickshire Partnership NHS Trust; H Crowson, Derbyshire Mental Health Services NHS Trust; K. Higgins, Dudley and Walsall Mental Health NHS Trust; N Green, Humber Mental Health Teaching NHS Trust; A Lodwick, Hywel dda Health Board; N Jacobs, Kent and Medway NHS and Social Care Partnership Trust; C Newell, Kimmeridge Court, Dorset Healthcare University NHS Foundation Trust; J Morgan, Leeds Partnership NHS Foundation Trust and St George’s University of London; J Arcelus, Leicestershire Partnership NHS Trust; H Birchall, Lincolnshire Partnership NHS Foundation Trust; R Thompson, Norfolk and Waveney Mental Health Foundation Trust; H Stephens, North Bristol NHS Trust; I Lea, North Essex Partnership Foundation NHS Trust; L Addicott, Nottinghamshire Healthcare NHS Trust; S Sankar, Northamptonshire Healthcare NHS Trust; J Holliday, Oxford Health NHS Foundation Trust; B Waites, Powys Local Health Board; H Strachan, Royal Bolton Hospital; A Fennell, Black Country Partnership NHS Foundation Trust; A Wolton, Somerset Partnership NHS Foundation Trust; H Gahan, South Essex Partnership University NHS Foundation Trust; G Moss, Sheffield Children’s Hospital; J Orme, Sheffield Health and Social Care NHS Foundation Trust; K Moore, South Staffordshire and Shropshire Healthcare NHS Foundation Trust; G Burgoyne, Suffolk Mental Health Partnership NHS Trust; I. Eisler, South London and Maudsley NHS Foundation Trust; B Bamford, South-West London and St George’s Mental Health Trust; I Yi, Surrey and Borders Partnership NHS Foundation Trust; and P Parker, Worcestershire Mental Health Partnership NHS Trust.

Abbreviations

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

CR was a project coordinator for the Experienced Carers Helping Others (ECHO) study and carried out data collection, statistical analysis and drafted the manuscript. EB prepared data for analysis. RH was a project coordinator for ECHO, involved in the setup of the ECHO study, carried out data collection and critical appraisal of the manuscript content. EG, PM, SG, and US were involved in the design and setup of the study and contributed to the interpretation of data and critical appraisal of the manuscript content. SG was also Principal Investigator at one of the study recruitment sites. KT contributed to the interpretation of data and critical appraisal of the manuscript content. NM conducted the Development and Well-being Assessment clinician ratings, supervised statistical analysis, contributed to interpretation of data and was involved in revising the manuscript critically for important intellectual content. JT conceived of the study, participated in its design and coordination, contributed to the interpretation of results, and was involved in drafting of the manuscript and revising it critically for important intellectual content. All authors read and approved the final manuscript.

Contributor Information

Charlotte Rhind, Email: [email protected] .

Elena Bonfioli, Email: [email protected] .

Rebecca Hibbs, Email: [email protected] .

Elizabeth Goddard, Email: [email protected] .

Pamela Macdonald, Email: moc.liamg@04dlanodcamalemap .

Simon Gowers, Email: [email protected] .

Ulrike Schmidt, Email: [email protected] .

Kate Tchanturia, Email: [email protected] .

Nadia Micali, Email: [email protected] .

Janet Treasure, Email: [email protected] .