When OCD Gets Stuck on
Food and Body Image
Andrea Kulberg, PhD
Shira Evans, MS, RD, CSSD, LD
Outline
• Three primary ways OCD “gets stuck”
• Three compensatory behaviors in OCD
• Interactive case studies
OCD Gets Stuck
• Irrational food fears and rigidity/rules about food
• The body image ideal
• Health anxiety
Irrational Food Thoughts Body Image Ideal
Health Anxiety
↓
Narrowed Food Variety
↓
Reduced Oral Intake
↓
Weight Loss
↓
Eating Disorder Treatment
Three Compensatory Behaviors That Grow OCD
1. Avoidance
• To escape a feared outcome and decrease anxiety in the
moment
• Promotes additional irrational fears, and leads to more
avoidance, in a vicious cycle
2. Reassurance Seeking
• Pursuing approval on health-related concerns from other
people or the Internet
• There can be no certainty one is healthy enough, so this
becomes an endless pursuit…there is never enough
reassurance
3. Compulsions
• Behaviors that reduce anxiety over intrusive thoughts
(e.g., “What if I’m unhealthy?” or “What if I’m fat?”)
What happens to the body?
• Physically: Weight loss
• Mentally: Increased health and body image thoughts
• Emotionally: Dulled and dysregulated  depression
Early Interventions
• Take warning signs seriously
• Consult with an RD who specializes in disordered eating;
weekly visits to start
• Examine family messages about food and exercise
• Consider messages from school and the community
Early Interventions
• Family-Based Approach
– Child is not involved in meal planning
– Parents make food choices
– Parents portion and plate foods
– Food choices are earned through age and demonstrated
recovery
– Child should not know their weight, blind weight measurements
Early Interventions
• Do not provide reassurance
• Ride the waves of distress
• This will feel uncomfortable
Early Interventions
• Components of an Incentive System
– Make a plan with your ERP therapist
– privileges are contingent upon meal plan completion
– Exercise should be temporarily eliminated
Recommended Support
• Employ a full multi-disciplinary treatment team (therapist,
MD, RD) and family-based approach is preferred
• Collaboration is key
• Educate yourself (“Help Your Teenager Beat an Eating
Disorder” by Lock & Le Grange)
• Take weight loss very seriously
Case study: “Abby”
• 16-year-old female
• History of weight cycling and OCD
• During the past 1-2 years child complains of foods causing
stomach pain
• Child is focused on appearance and a thin ideal
• After significantly reduced intake and self-reported pain after
eating, child is tested for multiple allergies and results indicate
no allergies
• After many medical visits, child continues to report intense
pain and "cannot eat“
Question 1: There are lots of battles at meal times, with the
child refusing to eat, complaining of stomach pain. The
parent should…
A. Let the child eat anything that doesn't hurt her stomach
B. Help the child look up heathy recipes on the Internet that
she agrees to eat
C. Take charge of everything the child eats and make the
child's privileges dependent on meal plan completion
D. Require the child to read about healthy body image so she
won't be so afraid to eat.
E. Wait for the child to say she is ready to eat feared foods
Question 2: The parent takes over the meal plan but the
child pushes back, increases exercise compulsions, skips
school meals, and loses more weight. The parent should…
A. Have child see a multi–disciplinary team, specializing in a family
based approach to eating disorders
B. Switch to an intuitive eating approach; controlling the child's meal
plan has clearly back-fired
C. Find a therapist trained in relaxation techniques so the child can
use this to calm down before meals and eat successfully
D. Supervise the child's lunch at school and discontinue all
exercise/sports.
E. Both A & D.
Question 3: The child improves her intake and gains some
weight, but still struggles with variety of food. What may be
supportive for child's treatment process?
A. The parent can now let go of deciding what the child eats
because the child is no longer in danger
B. More real-life exposures are needed, such as restaurant
outings, to be sure the child can eat a variety of foods
C. The parent should continue to be in charge of the child’s
intake
D. The child should now be allowed to resume her
sports/exercise.
E. Both B & C
Case 2: “Tim”
• 15-year-old male with low weight, purging behavior, and OCD
• Very focused on appearance, fashion and choosing healthy,
organic, locally-sourced foods
• Purging to decrease anxiety over the possibility that
something bad may happen to one of his parents
• Avoidance of public restrooms due to fears of becoming
contaminated or appearing disgusting to others
• Fear of developing brain cancer/health anxiety
Question 1: What type of food exposures would you
suggest for Tim’s treatment?
A. Feed Tim foods he considers to be safe and keep his anxiety at
a manageable level
B. Recommend yoga so Tim may use breathing to lower his anxiety
C. Feed Tim “unhealthy” foods and in a hierarchical fashion, from
least to most anxiety-producing
D. Encourage Tim to agree with thoughts that he may get brain
cancer and do not allow him to visit any doctors to get cancer scans
E. Both C & D
Question 2: How will you approach Tim’s purging behavior?
A. Teach Tim that anxiety isn’t dangerous, only uncomfortable
and it can’t make a person purge
B. Teach Tim that bad things may happen regardless of doing
compulsions (like purging), and he will have to accept that
possibility
C. Teach Tim thought-stopping tactics so his negative thoughts
disappear
D. Teach Tim positive thinking skills to combat his negative
thoughts
E. Both A & B
Question 3: What would you do to help Tim learn to use
public bathrooms?
A. Reward Tim with incentives for using a different public
restroom daily, working up from the easiest to hardest
B. Tell Tim to distract himself from his thoughts about appearing
disgusting to others
C. Tell Tim to find “safe” bathrooms and only use those
D. Teach Tim statistics about the low likelihood of getting sick
from going into a public restroom
E. Reassure Tim that everyone has to use public bathrooms
and he is not disgusting
Case 3: “Gracie”
• 10-year-old girl who reports gluten, dairy & fat are unhealthy
• Drops weight after cutting out these foods and demands that
her parents change the family diet
• In gym class at school she was weighed and told her BMI
• In health class, learned to avoid “junk food,” “foods with
chemicals”, and “processed foods”
• Won’t touch play-dough, looks away from monitor screens
• Runs on treadmill daily; won’t sit down at home or school
(watches TV standing up)
• Parents are disempowered
Question 1: What should the parent do about the
avoidance of gluten, dairy, and fats?
A. Most stores now offer gluten and dairy-free foods, so it is
okay to cut out a food group
B. There is an obesity epidemic, so it is alright if the child wants
to cut out fats
C. The parent should find a registered dietician for meal support
and slowly reintroduce gluten, dairy and fats
D. The parent should make the child smoothies and sneak in
the feared foods
E. Wait to feed the child feared foods until the child says
therapy is working
Question 2: What should parents do about Gracie’s
standing and running on the treadmill?
A. Exercise is good for lowering anxiety, so parents should not
discourage the child from movement
B. Gracie should be given a time-out whenever she is caught
standing or using the treadmill
C. Gracie’s parents should request special accommodations at
school due to her OCD, so she may stand during class time
D. Parents should create an incentive system to reward Gracie
for refraining from movement
E. Running on the treadmill is normal, but Gracie should be
required to sit down for school and TV
Question 3: Gracie gained back her weight but still avoids
some foods, and won’t touch “contaminants”, or look at
screens. What should her parents do?
A. Gracie should do exposures such as playing with playdough, finger-painting, and touching other “contaminants”
B. Gracie should do exposures such as looking at different
types of screens for extended time periods
C. Gracie should do exposures to touching feared foods
D. While doing exposures, Gracie should agree with thoughts
that she may become contaminated, won’t feel right, or that her
health may be damaged
E. All of the above
In Summary
• Early detection of eating disorders is possible
• Take food and body image related compulsions seriously
– no child should be on a diet
• A multi-disciplinary approach and exposure therapy are
key to recovery
• A family-based treatment approach is the gold standard
• For more info:
https://www.nationaleatingdisorders.org/resource-links
Questions?