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. Author manuscript; available in PMC: 2022 Oct 1.
Published in final edited form as: J Obsessive Compuls Relat Disord. 2021 Sep 20;31:100685. doi: 10.1016/j.jocrd.2021.100685

The Association of Obsessive-Compulsive Disorder, Anxiety Disorders, and Posttraumatic Stress Disorder with Impairment Related to Eating Pathology

Antonia N Kaczkurkin a,b, Wenting Mu a, Thea Gallagher a, Shari Lieblich a, Jeremy Tyler a, Edna B Foa a
PMCID: PMC8513719  NIHMSID: NIHMS1743500  PMID: 34660185

Abstract

Prior work has shown a number of similarities between obsessive-compulsive disorder (OCD) and eating disorders such as perfectionism and depressive symptoms. However, distress and impairment due to eating pathology are also highly comorbid with other disorders, which brings into question whether the relationship with eating pathology is unique to OCD. The aims of the current study were 1) to test perfectionism and depression as mediators of the relationship between OCD and eating pathology, and 2) to determine whether OCD is related to greater distress/impairment regarding eating habits, exercising, or feelings about eating, shape, or weight above and beyond other disorders. Symptoms were assessed in 329 treatment-seeking patients in a secondary analysis of a clinical battery. The results showed that depressive symptoms and perfectionism were found to mediate the relationship between OCD and eating pathology. Additionally, a regression analysis showed that OCD, social anxiety disorder, and panic disorder symptoms were associated with eating pathology to a greater extent than other disorders. These results suggest that distress and impairment related to eating habits, exercising, or feelings about eating, shape, or weight are not unique to OCD and that depression and perfectionism may, in part, explain the association between OCD and eating pathology.

Keywords: obsessive-compulsive disorder, eating pathology, anxiety, posttraumatic stress disorder, perfectionism

Obsessive-compulsive disorder (OCD) and eating disorders share many features in common. Both OCD and eating disorders are characterized by repetitive/ritualistic behaviors (Godier & Park, 2014; Herpertz-Dahlmann, 2009; Leonard & Riemann, 2012; Steinglass & Walsh, 2006), cognitive rigidity (Abbate-Daga et al., 2011; Meiran, Diamond, Toder, & Nemets, 2011; Tchanturia et al., 2004; Whitton, Henry, & Grisham, 2014), excessive habit formation/learning (Gillan & Robbins, 2014; Steinglass & Walsh, 2006), impulsive behaviors (Claes, Vandereycken, & Vertommen, 2005; Hisato Matsunaga et al., 2005; Waxman, 2009), and intrusive thoughts (Belloch, Roncero, & Perpiñá, 2016). In addition to these similarities, OCD is one of the most common comorbidities found in those with eating disorders. In a sample of 672 individuals with anorexia nervosa and/or bulimia nervosa, the most common comorbid disorder was OCD with a prevalence rate of 41% (Kaye, Bulik, Thornton, Barbarich, & Masters, 2004). This has led some researchers to suggest that OCD and eating disorders may fall within a similar spectrum of related disorders (Altman & Shankman, 2009).

Of the traits found to be common between OCD and eating disorders, perfectionism is one of the most well-studied. Both OCD and eating disorders demonstrate perfectionistic tendencies (Anderluh, Tchanturia, Rabe-Hesketh, & Treasure, 2003; Maia et al., 2009; Pinto et al., 2017; Sassaroli et al., 2008; Wade, O’Shea, & Shafran, 2015). Perfectionism is also associated with depression (Flett, Nepon, Hewitt, & Fitzgerald, 2016), which represents another common comorbidity of OCD (Ruscio, Stein, Chiu, & Kessler, 2010) and eating disorders (N. Godart et al., 2015). Depressive symptoms and perfectionism share many overlapping traits. For example, perfectionistic thought patterns have been found to be highly associated with intrusive thinking and rumination (Flett, Madorsky, Hewitt, & Heisel, 2002), which represents a psychological vulnerability for emotional distress, depression, high self-criticism, and cognitive biases towards minimizing successes while being cognitively vigilant towards perceived failures (Besser, Flett, Hewitt, & Guez, 2008; S. J. Egan, Wade, & Shafran, 2011; Flett et al., 2016; Shafran, Cooper, & Fairburn, 2002). Thus, it is possible that the commonalities between OCD and eating disorders may be due to shared perfectionistic and depressive tendencies.

However, examination of the comorbidity rates of eating disorders with other anxiety and related disorders brings into question whether OCD and eating disorders should be considered on the same spectrum. Here we make the distinction between OCD and related disorders, which are considered a separate category in the Diagnostic and Statistical Manual of Mental Health Disorders (5th ed.; DSM-5), from the anxiety disorders (generalized anxiety disorder (GAD), social anxiety disorder (SAD), and panic disorder) and from trauma- and stressor-related disorders (posttraumatic stress disorder (PTSD)). Studies have shown that the onset of anxiety disorders precedes the onset of an eating disorder (C. M. Bulik, 2002) and early trauma of all types is associated with an increase in eating disorder prevalence (Molendijk, Hoek, Brewerton, & Elzinga, 2017). The prevalence rates of comorbid anorexia nervosa and/or bulimia nervosa are high in GAD (NT Godart, Flament, Lecrubier, & Jeammet, 2000; Kaye et al., 2004; Lilenfeld et al., 1998), SAD (Brewerton, Stellefson, Hibbs, Hodges, & Cochrane, 1995; Hinrichsen, Waller, & van Gerko, 2004; Kaye et al., 2004), panic disorder (Kaye et al., 2004; Piran, Kennedy, Garfinkel, & Owens, 1985), and PTSD (Gleaves, Eberenz, & May, 1998; Turnbull, Troop, & Treasure, 1997). The high comorbidity between these disorders brings into question whether the relationship between OCD and eating disorder symptoms is unique to OCD.

Most previous studies on the relationship between OCD and eating disorders do not account for either the high comorbidity across anxiety and related disorders or the influences of perfectionism and depressive symptoms. Additionally, there are currently few studies on whether OCD is associated with the broader concept of eating pathology, which we define as distress/impairment related to eating habits, exercising, or feelings about eating, shape, or weight. Thus, the current study has two aims. The first aim was to determine whether the relationship between OCD and distress/impairment due to eating pathology is explained by depressive symptoms and/or perfectionism. To this end, we examined whether depressive symptoms and perfectionism mediated the relationship between OCD and eating pathology distress/impairment. The second aim was to examine whether OCD is related to distress/impairment due to eating pathology above and beyond anxiety disorders (GAD, SAD, and panic) and related disorders (PTSD) in a secondary analysis of a clinical battery. We tested whether OCD showed the strongest relationship with eating pathology distress/impairment, even after controlling for GAD, SAD, panic, and PTSD symptoms. We also controlled for depressive symptoms in the analyses. In addition, based on evidence that certain OCD symptom domains may be more related to eating pathology than others (H. Matsunaga, Kiriike, Miyata, et al., 1999), we also examined which OCD symptom categories (washing, checking, ordering, obsessing, hoarding, and mental neutralizing) showed the strongest association with distress/impairment related to eating pathology.

Methods

Participants

Participants were 329 adults (age: M = 31.32 years, SD = 11.92 years) seeking treatment at an outpatient clinic that specializes in anxiety disorders in Philadelphia, PA. Participants had a primary diagnosis of an anxiety or anxiety-related disorder as determined by Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria (American Psychiatric Association, 2013). Diagnostic intake interviews were conducted by trained clinicians using the screener and modules of the Mini-International Neuropsychiatric Interview (MINI) (Sheehan, Lecrubier, Sheehan, & Amorim, 1998) during a 2 hour intake appointment that also included disorder-specific assessments such as the Yale–Brown Obsessive Compulsive Scale (Y-BOCS) (Goodman et al., 1989), the generalized anxiety disorder (GAD) module of the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) (Brown, DiNardo, & Barlow, 1994), the Posttraumatic Stress Disorder Symptom Scale Interview for DSM-5 (PSS-I-5) (Foa, McLean, Zang, Zhong, Rauch, et al., 2016), and the Liebowitz Social Anxiety Scale (LSAS) (Heimberg et al., 1999). The most commonly diagnosed primary disorders included obsessive-compulsive disorder (OCD), generalized anxiety disorder (GAD), social anxiety disorder (SAD), posttraumatic stress disorder (PTSD), panic disorder, specific phobia, and other/unspecified anxiety disorder. Many patients also met criteria for a secondary diagnosis of major depressive disorder (MDD). Inclusion criteria for the current study included: age 18 years or older and a primary diagnosis of an anxiety or anxiety-related disorder. Exclusion criteria included: having a primary diagnosis other than the anxiety or related disorders listed above, having active suicidality, having a diagnosis of schizophrenia without a stable medication regimen or having more than mild current symptoms of psychosis even while on a stable antipsychotic medication regimen, evidence of intellectual disability or autism, and evidence of primary substance or alcohol dependence. Table 1 shows the demographics for the sample. Primary, secondary, and tertiary diagnoses are presented in Table 2.

Table 1.

Sample Demographics.

N %
Gender
 Female 177 53.8%
 Male 148 45.0%
 Transgender 1 .3%
 Other 3 .9%
Race
 White 266 80.9%
 Asian 26 7.9%
 Multiracial 16 4.9%
 Hispanic 9 2.7%
 African American 8 2.4%
 Other 4 1.2%
Level of Education
 No degree 9 2.7%
 High school diploma/GED 104 31.6%
 Associates degree 12 3.6%
 Bachelor’s degree 123 37.4%
 Master’s degree 53 16.1%
 Doctoral degree 28 8.5%
Relationship status
 Single 151 45.9%
 In a relationship 53 16.1%
 Living with partner 34 10.3%
 Married 81 24.6%
 Separated 4 1.2%
 Divorced 6 1.8%
Employment status
 Full-time 131 39.8%
 Part-time 42 12.8%
 Retired 10 3.0%
 Student 94 28.6%
 Disabled 7 2.1%
 Unemployed, looking for work 16 4.9%
 Unemployed, not looking for work 21 6.4%
 Other 8 2.4%
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Table 2.

Primary, Secondary, and Tertiary Diagnoses

Age
Female
Primary Diagnosis
Secondary Diagnosis
Tertiary Diagnosis
M (SD) % N % N % N %
OCD 29.77 (11.30) 52.9% 121 37.0% 5 2.7% 5 5.7%
GAD 32.91 (13.15) 62.5% 48 14.7% 20 11.0% 9 10.3%
SAD 28.48 (8.07) 32.6% 46 14.1% 22 12.1% 5 5.7%
PTSD 30.37 (10.58) 71.4% 35 10.7% 6 3.3% 2 2.3%
Panic Disorder 37.25 (13.50) 56.0% 25 7.6% 10 5.5% 2 2.3%
Specific Phobia 37.67 (16.56) 66.7% 9 2.8% 7 3.8% 2 2.3%
MDD 26.73 (5.99) 50.0% 6 1.8% 59 32.4% 21 24.1%
Other 34.05 (14.03) 51.4% 37 11.3% 53 29.1% 41 47.1%
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Note. OCD = Obsessive-compulsive Disorder; GAD = Generalized Anxiety Disorder; SAD = Social Anxiety Disorder; PTSD = Posttraumatic Stress Disorder; MDD = Major Depressive Disorder.

Procedures

Study procedures are described in detail in the main outcome paper for this study (Asnaani, Benhamou, Kaczkurkin, Turk-Karan, & Foa, 2019). Briefly, all study procedures were approved by the Institutional Review Board at the University of Pennsylvania and all participants provided informed consent. Potential participants were screened during a 20 to 30-minute initial phone screen by a trained research assistant who assessed for primary anxiety and related symptoms and exclusion criteria (see above). Eligible participants were assessed by a trained clinician during a 2-hour intake session and completed a pre-treatment self-report questionnaire packet using a secure online database: REDCap (Harris et al., 2009). Only baseline data was used in the current study.

Measures

Clinical Impairment Assessment Questionnaire (CIA).

The CIA (Bohn et al., 2008) is a 16-item self-report measure of the severity of distress/impairment related to eating habits, exercising, or feelings about eating, shape, or weight. Items are assessed on a scale from 0 (not at all) to 3 (a lot). A global impairment scores is calculated by summing the items. The CIA has shown high levels of internal consistency, construct and discriminant validity, test-retest reliability, and sensitivity to change (Bohn et al., 2008). This measure demonstrated excellent internal consistency in the current sample (Cronbach’s α = .96).

Obsessive Compulsive Inventory (OCI-R).

The OCI-R (Foa et al., 2002) is an 18-item self-report questionnaire assessing the presence and severity of OCD symptoms. Items are measured on a scale from 0 (not at all) to 4 (extremely). In addition to a total score, the OCI-R items can be grouped into six symptom categories: washing, checking, ordering, obsessing, hoarding, and mental neutralizing. This measure has demonstrated high internal consistency (α = .90) and good test-retest reliability (r = .82) in prior work (Foa et al., 2002). Internal consistency for the OCI-R in the current sample was very good (α = .89).

Generalized Anxiety Disorder, 7-item scale (GAD-7).

The GAD-7 (Spitzer, Kroenke, Williams, & Löwe, 2006) is a 7-item self-report measure assessing the frequency of generalized anxiety symptoms rated on a scale from 0 (not at all) to 3 (nearly every day). An extra item assesses overall difficulty associated with the previously endorsed items, rated from not difficult at all to extremely difficult. The GAD-7 shows excellent internal consistency (α = .92) and good test-retest reliability (r = .83) in prior studies (Spitzer et al., 2006). In the current study, the GAD-7 also showed very good internal consistency (α = .89).

Social Phobia Inventory (SPIN).

The SPIN (Connor et al., 2002) is a 17-item self-report scale that measures fear, avoidance, and physiological discomfort in social situations. Discomfort in the past week is evaluated on a 5-point scale ranging from 0 (not at all) to 4 (extremely). Prior research has demonstrated that the SPIN shows excellent internal consistency (α = .94), good test-retest reliability (r = .90), and good convergent validity with other measures of social anxiety (Connor et al., 2002). In the current sample, the SPIN also showed excellent internal consistency (α= .95).

Posttraumatic Diagnostic Scale for DSM-5 (PDS-5).

The PDS-5 (Foa, McLean, Zang, Zhong, Powers, et al., 2016) is a 24-item self-report measure that assesses PTSD symptoms and severity according to DSM-5 criteria. Responses are rated on a 5-point Likert scale from 0 (not at all) to 4 (6 or more times a week severe). The PDS-5 demonstrates excellent internal consistency (α = .95), good test-retest reliability (r = .90), and good convergent validity with other measures of PTSD, including the PTSD Checklist, Specific Version and the PTSD Symptom Scale—Interview Version for DSM-5 (Foa, McLean, Zang, Zhong, Powers, et al., 2016). The PDS-5 also showed excellent internal consistency in the current study (α = .96).

Panic Disorder Severity Scale (PDSS).

The PDSS (Houck, Spiegel, Shear, & Rucci, 2002) is a 7-item self-report scale measuring panic disorder symptoms, including frequency, distress, interoceptive and agoraphobic fear and avoidance, and social/work functioning impairment. Responses are rated on a scale of 0 (none) to 4 (extreme). The PDSS showed excellent internal consistency (α = .92) and good test-retest reliability (r = .81) in prior research (Houck et al., 2002). Internal consistency was also excellent in the current sample (α = .93).

Beck Depression Inventory II (BDI-II).

The BDI-II (Beck, Steer, & Brown, 1996) is a 21-item self-report measure used to assess the severity of depressive symptoms. Each item is scaled from 0 (no disturbance) to 3 (maximal disturbance). A total severity score is obtained by summing the item scores. In previous studies, the BDI-II shows excellent internal consistency (α = .91) and high correlations with other depression measures (Beck et al., 1996). The BDI showed excellent internal consistency in the current sample (α = .93).

Perfectionism Cognitions Inventory (PCI).

The PCI (Flett, Hewitt, Whelan, & Martin, 2007) is a 25-item self-report questionnaire assessing the frequency of automatic thoughts about perfectionism. Each item is assessed on a scale from 0 (not at all) to 4 (all of the time) and is intended to represent biased attention towards perfectionistic striving, rumination on perceived failures, and perseveration on the need to be perfect (Flett et al., 2007). A total score is obtained by summing the items. In prior research, the PCI has shown high internal consistency and test-retest reliability (Flett et al., 2007). In the current study, the PCI demonstrated excellent internal consistency (α = .97).

Data Analysis

All analyses were conducted using IBM SPSS Statistics, version 26. Analyses were conducted on the full sample of 329 participants. First, we report the correlations between eating pathology and each symptom measure. Next, we tested whether perfectionism and depressive symptoms mediated the relationship between OCD and distress/impairment related to eating pathology. The indirect effect was tested using bootstrapping procedures, which make fewer assumptions about the sampling distribution (Preacher & Hayes, 2008). This procedure involves computing unstandardized indirect effects for each of 10,000 bootstrapped samples and calculating the 95% confidence interval (Shrout & Bolger, 2002). Additionally, we examined the specificity of the relationship between OCD and distress/impairment related to eating pathology. In particular, we were interested in determining which symptom measure predicted greater distress/impairment due to eating pathology, while controlling for the overlapping variance between disorders. To do this, we used a multiple regression model with the symptom measures (OCI-R, GAD-7, SPIN, PDS-5, PDSS) as predictors of distress/impairment related to eating habits, exercising, or feelings about eating, shape, or weight as measured by the CIA. The relative contribution of each symptom measure to eating pathology scores was evaluated using standardized betas. To better understand the types of symptoms that might be contributing to our results, we also examined the OCD symptom categories of washing, checking, ordering, obsessing, hoarding, and mental neutralizing as predictors of distress/impairment due to eating pathology. Finally, to examine the impact of depressive symptoms, we repeated our analysis with the BDI-II as an additional covariate.

Results

Correlations between symptom measures and distress/impairment due to eating pathology

First, we examined the correlations between distress/impairment due to eating pathology and all measures. Distress and impairment related to eating habits, exercising, or feelings about eating, shape, or weight as measured by the CIA was positively correlated with all symptom measures (OCI-R, GAD-7, SPIN, PDS, PDSS). See Table 3 for means, standard deviations, correlation coefficients, and significance levels. Distress/impairment due to eating pathology was also associated with greater depressive symptoms on the BDI-II. In a subset of participants (n=162) with data collected on perfectionism as measured by the PCI, distress/impairment due to eating pathology was positively associated with perfectionistic tendencies.

Table 3.

Means, standard deviations, and intercorrelations between variables

1 2 3 4 5 6 7 8
Variable
1. CIA -
2. OCI-R .34*** -
3. GAD-7 .38*** .41*** -
4. SPIN .36*** .27*** .37*** -
5. PDS-5 .32*** .21*** .33*** .30*** -
6. PDSS .36*** .19*** .51*** .27*** .40*** -
7. BDI-II .55*** .43*** .64*** .48*** .46*** .47*** -
8. PCI .49*** .39*** .54*** .40*** .34*** .27*** .48*** -
M 11.00 16.35 12.50 23.04 12.90 7.80 21.27 45.20
SD 11.78 12.67 5.91 16.86 20.12 7.01 12.56 27.37
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Note.

*

p < .05;

**

p ≤ .01;

***

p ≤ .001;

CIA = Clinical Impairment Assessment questionnaire for eating pathology; OCI-R = Obsessive-Compulsive Inventory-Revised; GAD-7 = Generalized Anxiety Disorder 7-item scale; SPIN = Social Phobia Inventory; PDS-5 = PTSD Diagnostic Scale for DSM-5; PDSS = Panic Disorder Severity Scale; BDI-II = Beck Depression Inventory, Second Edition; PCI = Perfectionism Cognitions Inventory; M = mean; SD = standard deviation.

Depressive symptoms and perfectionism as mediators of the relationship between OCD and distress/impairment due to eating pathology

Given the relationships between OCD, distress/impairment related to eating pathology, depressive symptoms, and perfectionism, we examined the BDI-II and PCI as mediators of the relationship between the OCI-R and CIA. Using bootstrapped confidence intervals, the BDI-II and PCI significantly mediated the relationship between OCD symptoms and the CIA (Figure 1; Table 4). The indirect effect tested using a bootstrap estimation approach with 10,000 samples was significant (b = 0.28, SE = 0.05, 95% CI = 0.19, 0.39). Approximately 42% of the variance in eating pathology distress/impairment was accounted for by the OCI-R, BDI-II, and PCI (R2 = .421). The bootstrapped results also provide a confidence interval for the contrast between the PCI and the BDI-II to test whether one of the indirect effects is stronger. The contrast was not significant (CI = −0.02, 0.24), demonstrating that the indirect effect via the PCI is not greater than the indirect effect via the BDI-II. This suggests that both mediators contribute about the same to the relationship between OCD and distress/impairment due to eating pathology.

Figure 1. Depressive symptoms and perfectionism mediate the relationship between OCD symptoms and eating pathology.

Figure 1.

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The relationship between OCD and distress/impairment related to eating pathology (c path) becomes less significant after accounting for depressive symptoms and perfectionism (c’ path), consistent with a mediating effect. For estimates, standard errors, t-values and p-values for each path, see Table 5. CIA = Clinical Impairment Assessment questionnaire for eating pathology; OCI-R = Obsessive-Compulsive Inventory-Revised; BDI-II = Beck Depression Inventory, Second Edition; PCI = Perfectionism Cognitions Inventory.

Table 4.

BDI-II and PCI mediate the relationship between OCI-R and CIA

B SE t p
a1 (OCI-R → BDI-II) 0.45 0.07 6.11 <.001
a2 (OCI-R → PCI) 0.82 0.15 5.32 <.001
b1 (BDI-II → CIA) 0.42 0.07 5.77 <.001
b2 (PCI → CIA) 0.11 0.03 3.29 .001
c (OCI-R → CIA) 0.42 0.07 5.75 <.001
c’ (OCI-R → BDI-II & PCI → CIA) 0.14 0.07 2.05 .042
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Note. CIA = Clinical Impairment Assessment questionnaire for eating pathology; OCI-R = Obsessive-Compulsive Inventory-Revised; BDI-II = Beck Depression Inventory, Second Edition; PCI = Perfectionism Cognitions Inventory.

Symptom measures as predictors of distress/impairment due to eating pathology

Next, we examined whether the relationship between OCD and distress/impairment related to eating pathology was specific to OCD, or whether this relationship was apparent in other disorders as well. To do this, we controlled for the overlapping variance between disorders by including all symptom measures in one model. The regression model with the symptom measures (OCI-R, GAD-7, SPIN, PDS-5, PDSS) as predictors of the CIA was significant (F(5,323) = 24.37, p = <.001, R2 = .27) and showed that the OCI-R, SPIN, PDS-5, and PDSS all significantly predicted distress/impairment regarding eating pathology (Table 5). To better understand the types of OCD symptoms that might be contributing to the OCI-R results, we then examined which category of OCD symptoms (washing, checking, ordering, obsessing, hoarding, or mental neutralizing) had the strongest relationship with the CIA. The overall model was significant (F(10, 318) = 13.17, p = <.001, R2 = .29) and showed that distress/impairment related to eating pathology was associated with greater obsessing symptoms and, to a lesser extent, greater ordering symptoms (Table 5).

Table 5.

Predictors of eating disorder symptoms as measured by the CIA

Anxiety measures β B SE t p
OCI-R 0.19 0.18 0.05 3.66 <.001
GAD-7 0.10 0.21 0.12 1.71 .088
SPIN 0.19 0.13 0.04 3.56 <.001
PDS-5 0.12 0.07 0.31 2.32 .021
PDSS 0.17 0.28 0.10 2.91 .004
OCD symptom categories β B SE t p
washing −0.01 −0.03 0.22 −0.12 .906
checking −0.89 −0.34 0.23 −1.49 .138
ordering 0.12 0.47 0.24 1.99 .048
obsessing 0.13 0.37 0.17 2.18 .030
hoarding 0.07 0.29 0.24 1.19 .235
mental neutralizing 0.09 0.39 0.27 1.42 .156
BDI-II as additional covariate β B SE t p
OCI-R 0.13 0.12 0.05 2.42 .016
GAD-7 −0.05 −0.10 0.13 −0.82 .415
SPIN 0.11 0.08 0.04 2.16 .032
PDS-5 0.04 0.02 0.03 0.69 .492
PDSS 0.12 0.21 0.09 2.21 .028
BDI-II 0.40 0.38 0.06 5.94 <.001
PCI as additional covariate β B SE t p
OCI-R 0.21 0.22 0.07 2.99 .003
GAD-7 −0.08 −0.17 0.19 −0.87 .388
SPIN 0.16 0.12 0.05 2.19 .030
PDS-5 0.07 0.05 0.05 0.98 .329
PDSS 0.27 0.49 0.14 3.52 <.001
PCI 0.29 0.14 0.04 3.70 <.001
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Note. CIA = Clinical Impairment Assessment questionnaire for eating pathology; OCI-R = Obsessive-Compulsive Inventory-Revised; GAD-7 = Generalized Anxiety Disorder 7-item scale; SPIN = Social Phobia Inventory; PDS-5 = PTSD Diagnostic Scale for DSM-5; PDSS = Panic Disorder Severity Scale; BDI-II = Beck Depression Inventory, Second Edition; PCI = Perfectionism Cognitions Inventory.

Given the high correlations between depressive symptoms and both the CIA and OCI-R, we also tested the symptom measures as predictors of CIA scores while adding the BDI-II to the model. The regression analysis was significant (F(6, 321) = 27.89, p = <.001, R2 = .34) and continued to show that the OCI-R, SPIN, and PDSS were significantly associated with distress/impairment due to eating pathology, while the PDS-5 was no longer significant (Table 5). Furthermore, the BDI-II showed the strongest relationship with distress/impairment due to eating pathology of all the variables in the model, as shown by the standardized betas. Next, given prior work showing a relationship between eating disorder symptoms, OCD, and perfectionism, we included the PCI as an additional covariate. The model was significant (F(6, 155) = 17.44, p = <.001, R2 = .40) and, like the depression results, the OCI-R, SPIN, and PDSS continued to be significantly associated with distress/impairment related to eating pathology, while the PDS-5 was not (Table 5). Relative to the symptom measures, the PCI showed a stronger relationship with eating pathology distress/impairment, as indicated by the standardized betas.

Discussion

The aims of the current study were to 1) determine whether the relationship between OCD and distress/impairment due to eating pathology is explained by depressive symptoms and/or perfectionism, and 2) examine whether OCD is related to distress/impairment due to eating pathology above and beyond anxiety disorder symptoms (GAD, SAD, and panic) and related symptoms (PTSD). Both depressive symptoms and perfectionism significantly mediated the relationship between OCD and distress/impairment due to eating pathology. Correlational analyses revealed that distress/impairment regarding eating pathology was significantly associated with all symptom measures; however, correlations do not take into account the overlapping variance between these highly comorbid disorders. To address this, we tested the relationship between OCD and distress/impairment due to eating pathology while controlling for other symptom measures. The results demonstrated that distress/impairment related to eating pathology was not unique to OCD and was apparent in SAD, PTSD, and panic disorder as well. However, the results for PTSD became non-significant when controlling for either depressive symptoms or perfectionism. We then more closely examined the association between OCD and distress/impairment due to eating pathology and found that the relationship was driven mostly by obsessing symptoms and, to a lesser extent, ordering symptoms in OCD. Taken together, the results of this study suggest that distress and impairment related to eating habits, exercising, or feelings about eating, shape, or weight are not specific to OCD and that depression and perfectionism may, in part, explain the association between OCD and distress/impairment due to eating pathology.

Among the OCD symptom categories, obsessing and ordering were the most strongly associated with distress/impairment due to eating pathology in the current study. This might be the case because both OCD and eating pathology involve obsessive thoughts (one about harm, contamination, aggression etc. and the other about food, shape and weight). For example, the item “I find it difficult to control my own thoughts” on the OCI-R could apply to either obsessions in OCD or body preoccupation in eating pathology. The finding that distress and impairment related to eating pathology are not specific to OCD is consistent with a prior review showing that anorexia nervosa and bulimia nervosa are highly comorbid across many different anxiety disorders (Swinbourne & Touyz, 2007), suggesting that anxiety may represent a genetically mediated pathway to the development of an eating disorder (Kaye et al., 2004). Our results support and extend this work by showing a similar relationship with the broader conceptualization of eating pathology as distress/impairment regarding eating habits, exercising, or feelings about eating, shape, or weight. There have been discussions in the literature as to whether eating disorders should be subsumed into the OCD spectrum in the DSM (Hollander, Braun, & Simeon, 2008). At present time, eating disorders remain in their own category in the DSM 5. The results of the current study suggest that, while OCD is associated with distress/impairment related to eating pathology, this relationship is not unique to OCD and may be related in part to underlying depressive and perfectionistic symptomology.

Our results suggest that the relationship between OCD and distress/impairment related to eating pathology is accounted for in part by the combination of depressive symptoms and perfectionistic thought patterns. To measure perfectionism, we used the PCI, which reflects the frequency of discrepant thoughts between high striving expectations and one’s achievement of these standards. The perfectionistic thoughts measured by the PCI represent a more temporally sensitive aspect of perfectionism; they are intended to represent the state-like presentation of global, or trait, perfectionism (Flett et al., 2007). Coupled with elevated depression, perfectionistic thoughts may, in part, bridge the observed link between OCD and eating pathology. As mentioned previously, depressive symptoms and perfectionism share features in common such as rumination, self-criticism, and cognitive biases. It is possible that these overlapping attributes may be core features of both OCD and eating disorders. In fact, our mediation results support this hypothesis and suggest that depression and perfectionism, partly explain the relationship between OCD and distress/impairment due to eating pathology. However, depression and perfectionism do not account for all of the variance. There may be other factors besides depression and perfectionism that also contribute to the relationship between obsessive-compulsive symptoms and eating pathology, such as cognitive rigidity and emotion regulation difficulties. Future work would benefit from examining other constructs that might contribute to the relationship between OCD and eating pathology.

It is also possible that the contributions of perfectionism and depression may depend on the type of eating pathology present. For example, rigidity and perfectionism may be more prominent in anorexia nervosa and bulimia nervosa than in binge eating disorder. There is some support for this in the literature. Perfectionism, as measured by elevated concern over mistakes, has been associated with both anorexia nervosa and bulimia nervosa (C. Bulik et al., 2003). Additionally, prior work shows that OCD patients with comorbid anorexia nervosa or bulimia nervosa were significantly more likely to endorse the need for symmetry or exactness and ordering/arranging compulsions (H. Matsunaga, Kiriike, Iwasaki, et al., 1999; H. Matsunaga, Kiriike, Miyata, et al., 1999). Need for symmetry and order are conceptually related to perfectionism, as factor analytic models of perfectionism have demonstrated that order is a theoretically important component of perfectionism (Kim, Chen, MacCann, Karlov, & Kleitman, 2015). However, these studies did not include a comparison with binge eating disorder. In the current study, while our eating pathology measure did not allow for more nuanced exploration of the type of eating pathology, future work could examine whether the relationships between OCD, perfectionism, and depression are more prominent in one type of eating disorder over another.

Several limitations of the present study should be considered when interpreting the results. First, temporal precedence or causality cannot be inferred from the mediation results as the measures represent a single time point. Second, the participants were treatment-seeking individuals, which may limit the generalizability of these findings. Future studies should explore these relationships between distress/impairment related to eating pathology and OCD, anxiety, and PTSD and in other samples. Third, our study utilized self-report measures, which may be susceptible to recall bias and demand characteristics (Solhan, Trull, Jahng, & Wood, 2009). Future work should use clinician-administered measures like the Y-BOCS to measure symptom severity. Also, the eating pathology measure used in the current study (the CIA) is a measure of psychosocial impairment and distress due regarding eating habits, exercising, or feelings about eating, shape, or weight, rather than a measure of the eating disorder symptoms themselves (i.e., this questionnaire does not ask if people binge or purge or restrict). The current study should be replicated with a measure designed to capture specific eating disorder symptoms in order to determine whether certain symptoms (e.g., binging, purging, restricted intake) are more relevant to OCD. Finally, while many participants in this sample endorsed distress and impairment related to eating habits, exercising, or feelings about eating, shape, or weight, the clinic where this study was conducted is not an eating disorder clinic; therefore, these results need to be replicated in a sample that specifically recruits for eating disorder diagnoses.

The current study has strengths in spite of these limitations. For one, the sample size is large and has a large number of moderate to severe OCD patients assessed by expert clinicians. Also, despite discussions in the field that OCD and eating disorders may fall within a similar spectrum of related disorders (Altman & Shankman, 2009), there is a distinct lack of research in this area. Here we address this gap in the literature by examining the association between OCD, anxiety, and PTSD symptoms and distress/impairment related to eating pathology in a treatment-seeking clinical sample. Finally, we extend prior work by taking into account the overlapping variance between disorders and by controlling for important confounds such as depressive symptoms and perfectionism.

Further research examining the relationships between eating pathology and OCD would help to inform clinical efforts focused on successfully treating patients with these disorders. Some studies suggest that OCD and eating disorders may be associated with both common and distinct aspects of perfectionism (Yahghoubi & Mohammadzadeh, 2015); thus, examining specific types of perfectionism may be important for future work in this area. Also, the use of the PCI to measure the cognitive aspects of perfectionism (i.e., “Why can’t I be perfect?) allows for a temporally sensitive measure of what has traditionally been viewed as a trait-like construct (Flett et al., 2007). While this dimension of perfectionism is quite relevant to the study of eating pathology, other measures of perfectionism may provide more insight into the nature of comorbid eating pathology and OCD, anxiety, and/or PTSD symptoms. Finally, there is some evidence that perfectionistic tendencies impact treatment outcomes in OCD patients (Chik, Whittal, & O’Neill, 2008); however, no studies have investigated the role of perfectionistic cognitions, such as those measured by the PCI, in treatment studies. Thus, future studies could examine the specific role of perfectionistic cognitions in affecting treatment outcomes in anxiety and related disorders. Likewise, making perfectionism itself the focus of treatment could be useful. CBT can be used to address issues that underlie perfectionism such as fear of failure, a need to please others, and equating one’s sense of worth to achievements (S. Egan, Wade, Shafran, & Antony, 2016). Future work would also benefit from novel interventions aimed at addressing specific perfectionistic cognitions.

  • The study included 329 treatment-seeking patients of an anxiety clinic

  • Depression and perfectionism mediate the OCD-eating pathology relationship

  • Distress/impairment due to eating pathology is not unique to OCD

  • OCD, social anxiety, and panic all show associations with eating pathology

Acknowledgements

The authors would like to first express their sincerest appreciation to Dr. Edna B. Foa, who is the Director and Founder of the Center for the Treatment and Study of Anxiety (CTSA) at the University of Pennsylvania, who has generously supported the integration of research into the CTSA treatment clinic and has ensured that the entire clinical team at CTSA continues to provide evidence-based treatments to patients seeking treatment at our clinic. The authors would also like to acknowledge Jody Zhong, the research assistant who assisted heavily on the original creation of the REDCap database and data infrastructure, coordinated data collection and patient reminders, and assisted with creation of the database for analysis, and Kathy Benhamou, the subsequent research assistant who enhanced this infrastructure and greatly streamlined our processes to make the data collection and database creation what it is today. We would also like to thank Jesse McCann, who assisted in the cleaning and set-up of the full data examined in the current study and Jeremy Tyler, who oversees the management of the study.

The authors would like to acknowledge the creators of REDCap (Harris et al., 2009), the data acquisition program used to collect the data analyzed in the present study. This software reduced burden on patients by allowing them to provide responses at home, and facilitated easier and more accurate access of treatment outcome data compared to traditional paper and pencil formats.

Finally, we would also like to deeply thank all the patients seeking treatment at our Center who were willing to allow us to analyze their deidentified data in order to better understand the efficacy of our treatments on symptom reduction and other constructs of interest throughout their treatment at our facility.

Funding

Dr. Kaczkurkin’s contribution is supported in part by the National Institute of Mental Health (grant number: R00MH117274), a NARSAD Young Investigator Award from the Brain & Behavior Foundation, and a Research Fellowship from the Sloan Foundation.

Footnotes

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Conflict of interest

All authors declare that they have no conflicts of interest.

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