Orthorexia: Where Eating Disorders Meet OCD – Part 2

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Effective Strategies and Predictable Complications in the Treatment of Orthorexia

In our previous article about Orthorexia, we described this relatively unknown and misunderstood condition.  In this, the second and final installment in this series, we discuss strategies and pitfalls in the treatment of Orthorexia.

Orthorexia, being a somewhat new conceptualization of a psychological disorder, is under-researched and often misunderstood within the mental health and medical communities.  Many mental health professionals have found success treating individuals with Orthorexia using evidence-based treatment methods that are used to treat other Eating Disorders, OCD, and related OC Spectrum Disorders.

Cognitive-Behavioral Therapy (CBT) and Mindfulness are two highly effective treatment methods used to treat Orthorexia.  Using CBT, individuals with Orthorexia learn to challenge and change their distorted thoughts (cognitions) related to their body and the foods they eat.  Education about nutrition and what is considered “healthy” should also be integrated into CBT when treating Orthorexia, using logical, evidence-based strategies.

Using Mindfulness Based Cognitive Behavioral Therapies such as Acceptance and Commitment Therapy (ACT), clinicians can help those who suffer with Orthorexia to gain greater awareness and acceptance of uncomfortable thoughts, feelings, sensations and urges related to food and their body.  This approach also helps clients to become more aware of and conscious of their food consumption.  The goal is for clients to become more comfortable with their bodies and their actual health (as opposed to their feared bad health).  Using these techniques, sufferers can change their relationship with a variety of foods and with their food-related anxiety.

The primary behavioral component of treatment for Orthorexia is Exposure and Response Prevention (ERP).  Some common ERP assignments might include the following:

• Gradually introducing a broader variety of foods into the client’s diet, including healthy foods that the client has previously decided were unacceptable;
• Restricting, and ultimately eliminating time spent researching food;
• Restricting, and ultimately eliminating time spent discussing the health values of food;
• Returning to normal social interactions, including meals with others.

It is important to note here that clients are encouraged to eat a healthful diet.  Some mistakenly believe that giving up their Orthorexia eating style will be the same as eating a bad diet.  Nothing could be further from the truth.  The goal is not to help the client learn that all food is healthy – after all, there are foods that are legitimately unhealthy, especially if eaten to excess.  Rather, the goal is to help the client learn to have a more balanced perspective towards food, and to eat in a manner that is both healthy and enjoyable.  In other words, the goal is not to teach the client to eat a diet of Big Macs and Slurpees, but rather to be able to eat based on choice, not fear.

Orthorexia In Perspective

Diagnosing and treating Orthorexia can be complicated by a number of factors:

First, the culture at large, and the news media in particular, reinforce on a daily basis that we should be hyper-conscious of health, weight, and nutrition, and that we should eat as purely as possible.

Second, people who experience Orthorexia often do not see that their obsessive thoughts and compulsive behaviors are problematic.  They see their diets as ideal and healthy, and see others’ diets as disgusting and unhealthy.  Great pleasure and satisfaction are gained from the belief that they have mastered and will continue to perfect their diet.  This may become an issue during treatment, as sufferers are likely to initially reject any suggestion that their diet is problematic, and equally likely to resist the idea that change would benefit them in a positive way.

Third, those with Orthorexia may initially feel significant discomfort during the exposure therapy that is so critical to treatment.  Exposures typically involve eating foods that individuals with Orthorexia deem “unhealthy” or “impure”.  They may at first have a strong visceral reaction when trying foods that they have long identified as disgusting and toxic.  The ultimate goal of exposure is for the client to learn that they need not fear less-than-perfect foods, that they may actually enjoy such foods in moderation, and that eating them does not result in a catastrophic outcome.

Fourth, those with Orthorexia are even more likely than the average client to reject the use of anti-depressants and other medications that may potentially help to reduce their anxiety and obsessionality.  Individuals with Orthorexia frequently view such medications as “poison”, and clinicians should be prepared for the possibility that the client will never be open to pharmacotherapy in any way.

Orthorexia is a significant and growing problem that requires serious consideration by the medical and psychological communities.  While Orthorexia is not yet recognized by the APA as a formal, free-standing diagnosis, failure to accurately identify and treat the condition will result in serious problems for many people who don’t necessarily meet the requirements for a formal eating disorder diagnosis.  Fortunately, Orthorexia responds well to treatment with Cognitive Behavioral Therapy (CBT) and Mindfulness Based CBT, especially if the clinician is able to first help the sufferer recognize the excessive and distorted nature of their thoughts and behaviors related to food purity.

To read part one of our series on Orthorexia, click here.

•Kimberley Quinlan, MA, is a psychotherapist at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions, including Orthorexia.  In addition to individual therapy, the center offers six weekly therapy groups, as well as online therapy, telephone therapy, and intensive outpatient treatment.  To contact the OCD Center of Los Angeles, click here.

Tags: Anxiety, Cognitive-Behavioral Therapy (CBT), Compulsions, Eating Disorders, Food, Health, Mental Health, Mindfulness, Obsessions, Obsessive-Compulsive Disorder (OCD)

8 Comments to Orthorexia: Where Eating Disorders Meet OCD – Part 2

1. 

   Any thoughts about how orthorexia impacts parenting? This diagnosis sounds like a very good fit for my mother. Her intensely righteous and controlling behavior around what I was allowed to eat created a great deal of conflict between her and me when I was a child.

   I am thinking there might be some diagnosis like orthorexia by proxy, similar to the separate diagnoses of Munchausen’s Syndrome and Munchausen’s Syndrome by Proxy.

   I have often wondered if something like orthorexia played a part in Joel Steinberg’s murder of the child he had illegally adopted, Lisa. Descriptions of the child’s last night all mention that he fatally beat her out of anger that she hadn’t been drinking enough water. http://law.jrank.org/pages/3434/Joel-Steinberg-Trial-1988-89-Cocaine-Rage.html While this is usually described as a trivial reason for his rage that people usually attribute to drug use or sadism, I wonder if he also had controlling behavior around extreme food beliefs. While I was lucky my mother was not as troubled as Mr. Steinberg, my experiences with her made it very easy for me to imagine a parent going into an uncontrollable rage because a child hadn’t drunk 8 eight ounce glasses of water a day.
Ellen Schwartz on January 9th, 2012
2. 

   Ellen,

   Thank you for your comments.

   I hadn’t considered, nor have I ever seen, Orthorexia-by-proxy. But we have treated numerous cases of Hypochondria-by-proxy, in which someone worries obsessively not about their own health, but that of their child (or another person such as a spouse). I can see how that could be quite similar to your conceptualization of Orthorexia-by-proxy.

   As for the Steinberg case, I remember it well. And while I am not prepared to make a diagnosis of someone I have never met, I can say that news reports at the time indicated that Steinberg was sociopathic, and that his problem far exceeded anything related to Orthorexia.

   Ultimately, I think the main issue is that those who suffer from Orthorexia (whether it be a mother, child or anyone for that matter) do not know that their obsession actually has a name and that help is out there. Your question again confirms my reasoning for writing the article. Education and awareness about this disorder are crucial in order for those with Orthorexia to seek treatment. If you feel that your mother did suffer from Orthorexia (or Orthorexia-by-proxy) , I hope that my articles bring you clarity as to why she behaved the way she did.
Kimberley Quinlan, MA on January 14th, 2012
3. 

   Very interesting… thank you for this post; I have learned a lot. Do you think the fact that those with Orthorexia often derive pleasure from their obsessive compulsive behavior precludes this disorder from actually being a “type” of OCD? Those with OCD are distressed by their obsessions and compulsions. I’m also wondering how/why/when those with Orthorexia seek help, as they, unlike most OCD sufferers, do not realize their behavior is irrational.
   Thanks in advance for your insight!
Janet Singer on January 15th, 2012
4. 

   Thank you for your comment Janet. I appreciate your thoughts.

   We do not diagnostically conceptualize Orthorexia as being the same as OCD. As noted in my earlier article , we see it as being a hybrid of an eating disorder and Obsessive Compulsive Disorder. Essentially, we see it as an OC Spectrum Disorder.

   Like other eating disorders, Orthorexia is driven by anxiety and the thrill of being in control (which may in turn be mistakenly understood as pleasure). Similar to obsessions involved in OCD, the obsession of food perfection can be quite stressful and taxing. Just as those with OCD have a constant stream of “what if…” thoughts, those with Orthorexia constantly have obsessive thoughts along the lines of “Oh no, what if something toxic were to enter my body – that would be catastrophic“. These obsessive thoughts lead to compulsive and avoidant behaviors that are done in the hope of reducing anxiety, and gaining control and certainty.

   As you note, and as I mentioned in the article, those who suffer Orthorexia often resist treatment. They are less likely to seek help, until such time as their compulsive and avoidant behaviors have negatively impacted their life to the extent that they realize they have a problem. These negative, maladaptive behaviors often cause havoc to their health, social life, familial relations and overall psychological well being.
Kimberley Quinlan, MA on January 16th, 2012
5. 

   I really loved this article. It has been very helpful. I have suffered with orthorexia to some degree or another most of my adult life. I agree with the outlined treatments in which I have followed myself with success. Thanks again for the great information.
Lita on January 18th, 2012
6. 

   Lita,

   Thank you for your kind words. I’m glad you found the article helpful, and that you have had success in managing your Orthorexia using the principles of CBT. Keep up the good work.
Kimberley Quinlan, MA on January 18th, 2012
7. 

   The fact that orthorexia is generally ego-syntonic makes me wonder if it’s really more related to Obsessive-Compulsive Personality Disorder (OCPD) rather than OCD. Many of the stories told by orthorexics remind me of the behavior of people with OCPD that I’ve known. I also wonder if there’s a subtype that’s associated with autism-spectrum disorders, particularly if dietary purity is one of a few restricted interests.
ebohlman on August 17th, 2012
8. 

   Eric, your observations are very interesting. I myself haven’t correlated these similarities, but I can see your point of view. This brings up again the importance of correct diagnosis. If you are concerned about a loved one and feel that their dietary behaviors are problematic to their health, have them assessed by a mental health professional. Thank you for reading!
   Kimberley
Kimberley Quinlan, MA on August 30th, 2012

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