Anorexia Nervosa Is a Modern Obsessive-Compulsive Disorder

Focus on food and control in anorexia nervosa is basically obsessive-compulsive.

Posted Oct 10, 2018

Although all health workers are aware of the persistent and constant concern and preoccupation with food in anorexia nervosa — rejection or constant evacuation of food — few have focused on the intrinsically obsession-compulsive nature of this concern. Unlike the true reduction of appetite in depressive disorders, there is in anorexia a conscious and deliberate refusal of food. The lack of correct perception of bodily cues related to hunger is a late development in the course of the illness, but a striking early pre-starvation factor is the constant awareness of mild to strong feelings of hunger. In addition to this awareness of hunger, there is a persistent preoccupation with food in a concrete way in the form of ruminative calorie counting and mental imaging of food.

The diagnostic importance of the presence of actual hunger in anorexia and the concrete mental focus on food in both anorexia and the related bulimia involving excessive food gorging and vomiting have not previously been appreciated because the symptoms, on the surface, do not appear to be personally distorted or bizarre. Because these patients consciously and persistently pursue thinness, it appears at first that they are voluntarily attempting to attain a goal. However, as with classical obsessive-compulsive symptomatology involving involuntary hand-washing rituals and ruminative ideas, the goal involves an involuntary rumination on caloric numbers and on food, and it is experienced as out of the individuals’ control by the sufferers themselves. They cannot stop thinking about calories or about foods that they would like to eat throughout the day. They are preoccupied with urges to eat so-called “junk foods,” such as ice cream, French-fried potatoes, candy, and other sweets. Such foods are considered forbidden; they are negatively valued and thus become both strongly feared and deceitfully desired. In this kind of vivid, concrete preoccupation, persons suffering from eating disorders exhibit obsessional thinking whereby they keep emotions and wishes out of awareness but, as with all obsessional ruminative symptoms, they still experience gratifications in the mental image. Although recent studies have shown some behavioral and symptomatic differences between persons suffering from anorexia nervosa and those with bulimia alone, particularly a lack of consistency about weight loss in bulimia, the factor of obsessional preoccupation with images of food is common to both conditions.

Preoccupation with control is pervasive in the lives, personalities and symptomatology of persons with eating disorders.

They believe they can control all kinds of activities, especially creative ones (as dancers and performers). Directly involved in the relentless pursuit of thinness are control of weight, control of thought, and rituals that are attempts to gain control over the environment. There is a factor of control of bowel and urinary functions, because laxative and diuretic use is a constant feature of these conditions. Amenorrhea or absent periods is a physiological concomitant of the severe weight loss, and is also often experienced as a successful control of bodily functions. Anorexic persons themselves are often quite aware of their own concerns about control, and one often hears their rationalization, “I control what I eat and take in because I can’t control anything else in my life.” Rather than an insight, this formulation is an excuse for the focus on control, because the true impact is the reverse —i.e., the anorexic loses the actual mastery of living because of being so preoccupied with control in the first place. The severe control of eating and excretory functions leads to physical impairment and weakness, hospitalization, and eventual failures in interpersonal relationships. Not only is there constant attention to control of precise amount of food intake and precise weight, to the performance of controlling exercise as well as eating rituals involving special places to eat and ritualistic chewing and regurgitation, but the factor of control pervades all aspects of the person’s behavior. Emotions are carefully controlled and regulated, and loss of control of affect or emotion is a persistent fear. These individuals are notoriously sensitive to anyone else dictating anything to them about their bodies, and they must be in charge of when they eat, sleep or cry. Forced intratubal feeding, which often becomes necessary, is experienced as a total defeat and loss of control. If they enter into behavior therapy, in which the therapist introduces controlling reward and punishment, they do so with the greatest fear and trepidation because of relinquishing their own control. Concern about control is a core factor and obsessional ideation is an attempt to gain control over impulses.

Along with the defensive character structure of the obsessive-compulsive disorders, typical behavior patterns include the following: perfectionism, excessive orderliness and cleanliness, and meticulous attention to detail. Stubbornness and rigidity are very prominent and are major factors in the difficulty in effecting change with anorexic persons or in treating them successfully.

They resist all efforts at interfering with their persistent pursuit of thinness, or their ideas about their bodies and themselves. Scrupulousness, self-righteousness and miserliness are also often present, although the miserliness is sometimes hidden, or substituted for, by a spendthrift self-indulgence. Other, less specific features of the obsessive-compulsive character structure are negativism, rebelliousness and intense dedication to physical activity. The negativism is obvious in the principle of refusing to eat, and in the resistance to all positive efforts by others to reinstitute a healthy diet. Rebelliousness is not quite as flagrant with these conditions as it is with adolescent law-breaking and drug-taking, but no less dramatic is the picture of the conforming, well-behaved, obedient and high achieving teenager who suddenly defies a parent’s efforts at proper feeding. The paradox of the poor little rich girl who refuses to partake of the bounty of the family table and the virtual absence of eating disorders in underprivileged locales — e.g., Puerto Rico, India, New York slums— are testimony enough to the factor of rebellion. Alternations between compliance and rebellion, as well as over-compliant behavior, which is subtly rebellious and hostile in its nature, are present as typical obsessive-compulsive characteristics. The picture of a high level of physical activity and drive to exercise, requiring high degrees of energy in the face of severe weakness and thinness, results from the compulsive drive to excel and to succeed at the weight loss project in a virtually superhuman way.

Persons with eating disorders use laxatives on a regular ritualistic schedule and to an extent far beyond any conceivable realistic effect on weight loss. This is based on the observation that purgation causes water loss and some immediate weight reduction. That it is an ineffective means of long-term weight control is evident in the short duration of the effects. Diuretics are also used in ritualistic and excessive ways. These symptoms highlight the major disruption of the control phase (3-6 years) of their childhood development rather than a more superficial disruption of the earlier phase of focus on eating. Concerns about control and modulation of aggression and rage supersede the apparent focus on attachment and nurturance connected with eating and ingestion. 

Among young women of Westernized culture particularly, thinness and scrupulousness about food and eating as well have taken over in modern times as dominant achievement values and battlefields of competition. In such a social climate, the intensely achievement-oriented person with an obsessive-compulsive character structure has developed a new symptom picture and a modern syndrome. 

Food in this culture is plentiful, and eating for the sake of pleasure alone is emphasized. Value classifications of “good" and bad” foods and almost magical beliefs in the gratifying and health-bestowing attributes of food are pervasive. The obsessive-compulsive teenager is already vitally concerned with matters of goodness and badness, and acceptance or rejection of food becomes the symbolic arena of  conflict. Because of cultural and peer emphasis on thinness, rejection of food is a negative achievement so important and so critically pursued that it can lead to serious physical sequelae and even death.

Recognizing the intrinsic role of obsessive-compulsive patterns in the modern eating-disorder picture helps clarify some of the treatment problems in these conditions. Obsessive-compulsive patterns have historically been difficult to treat, whether through psychological, social or biological methods. Behavior modification approaches run the risk of substituting slightly more adaptive compulsive reward-and-punishment systems for the eating and food rituals. However, an enlightened recognition of and focus on the pervasive obsessive- compulsive defenses and character structure, through various types of psychotherapy, medication, or other means, can ameliorate the illness and be potentially life-saving.