Understanding Food Aversion, OCD, and Eating Difficulties

Introduction

Eating disorders are serious and complex mental health issues, where people develop unhealthy relationships with food, their body weight, and shape. People with eating disorders usually exhibit unusual behaviours around their eating habits.

The most characteristic features of these disorders are the behavioural disturbances displayed by the patient, such as persistent and often severe disruptions in eating habits and attitudes (Birmingham & Beaumont, 2004) and a distorted body image.

They are often either restricting food or calorie intake or indulging in purging behaviours by either throwing up, using laxatives, etc. These persistent conditions can greatly impact an individual's physical, social, and mental functioning. They could be caused by various reasons such as genetics, personality, social and cultural ideas around body weight and shape, and mental health issues such as anxiety.

The two most common eating disorders are bulimia nervosa and anorexia nervosa.

Anorexia Nervosa:

People struggling with Anorexia have a distorted view of their bodies. In line with this distortion, they limit their food intake. Additionally, to avoid gaining weight, they may also over-exercise and indulge in other activities that can lead to burning more calories. Anorexia can lead to serious physical conditions such as malnutrition, bone loss, hormonal imbalance, and heart ailments to name a few.

Bulimia Nervosa:

It is another eating disorder with a serious consequence towards one’s health. It is characterised by binge eating episodes, purging, and excessive preoccupation with body shape and weight. In the binge eating episode, an individual usually consumes unusually high amounts of food within a short period of time and frequently feels out of control. They might then experience guilt or shame, which makes them purge. Bulimia sufferers, in contrast to people with anorexia, often can maintain a ‘normal weight’, which hides the illness from outside observers. However, it can also result in major health concerns like teeth erosion, gastrointestinal disorders, and electrolyte imbalances.

Avoidant/Restrictive Food Intake Disorder (ARFID):

A person with avoidant/restrictive food intake disorder (ARFID) avoids or restricts their intake of specific foods, just like in any other eating disorder. This restriction is not due to a distorted sense of self or body image. People suffering from ARFID have fear or repulsion towards certain kinds of food. They may be afraid of being repulsive towards food of a certain texture, or smell and be afraid of the consequences of eating. They may fear that they would choke or vomit, or detest the sensory aspects of the food. Such restriction and avoidance of food especially in children and adolescents can result in nutritional deficits and healthy growth and development.

ARFID unlike bulimia and anorexia is due to aversion, fear, or anxiety to certain foods or the act of eating. Not primarily due to concerns around body weight or shape (read how to overcome body image issues).

Understanding Food Aversion

Food aversion is characteristic of strong and continuous avoidance of specific kinds of food. This is due to sensory problems or a perceived fear of the harmful outcome, eg. choking, vomiting, etc. Food aversion symptoms include having a specific or restricted diet, feeling distressed when exposed to certain meals which thereby causes anxiety, and refusing to eat specific food items.

One of the leading causes of food aversion is sensory problems, such as sensitivity to tastes, textures, or scents of various foods. For instance, someone may designate a disgusted feeling to a food item because they have a mushy texture or a strong smell. Henceforth, such avoidance can impact everyday life and social functioning negatively as well as cause an inability to fulfil a nutritional diet.

Avoidant/Restrictive Food Intake problem (ARFID) is a severe eating problem that has received little clinical recognition. Sensory problems or fear of unwanted outcomes is a characteristic of both the disorders, ARFID however results in severe nutritional deficits, excessive weight loss, and disruptions in development. Importantly, a distinguisher of ARFID from other eating disorders like bulimia or anorexia nervosa is that the sufferers do not usually worry about their weight gain or loss and body image. ARFID may need a more rigorous treatment and intervention approach.

Is Food Aversion a Symptom of OCD?

No, food aversion is not a sign of OCD in and of itself. However, both the disorders have common features. While in ARFID, the individual is restricting food intake due to anxiety or aversion.

In OCD, the individual experience certain obsessions (of various kinds and not limited to food) that leads to compulsive behaviours in an attempt to cope with the anxiety these ideas generate. For instance, someone may have an irrational fear of choking or contamination and create complex routines to protect themselves from these imagined threats.

An important link has been found between Obsessive-Compulsive Disorder (OCD) and ARFID. Rigid eating habits and thoughts are possible in both cases. As many as 40% of people experience both eating disorders and OCD simultaneously.

For example, the compulsions associated with OCD may be similar to the severe rules that an individual with ARFID may have regarding what foods are "safe" to eat. So while ARFID might not be a symptom of OCD, they might co-exist. Researches also suggest that people with ARFID and OCD may have similar personality traits such as perfectionism (Bardone-Cone et al., 2007;)

It is important to note that, compulsions around food can be an early sign of OCD and can resemble an aversion to certain foods. OCD sufferers may establish strict guidelines or customs around eating as a result of their obsessions with choking, contamination, or other anxieties. These obsessive habits may result in food aversion, defined as avoiding particular foods or eating environments.

Though the obsessive-compulsive cycle, not sensory problems or a fear of food-related negative consequences, is the primary cause of OCD, the behaviours that arise from it can be quite similar. Furthermore, OCD may play a role in the emergence of eating disorders since the obsessive urge to regulate eating behaviours may be identical to the signs of anorexia nervosa or ARFID.

However, the disease has a huge impact on eating tendencies that resemble food aversion. Obsessions—persistent thoughts and compulsions—repetitive actions carried out to lessen the anguish these obsessions are the hallmarks of OCD. These compulsions associated with eating might result in actions that resemble food aversion.

For example, an obsessive fear of food contamination may cause an OCD sufferer to avoid eating in particular areas. Additionally, they could establish obsessive food preparations like thoroughly cleaning or inspecting food for impurities repetitively. Similar to food aversion, these habits may lead to a restricted diet.

Furthermore, OCD in many situations may have a role in the emergence of eating problems. One prevalent characteristic of OCD is a need for control, which can here be extended to managing one's food intake and weight. This can show up as obsessive eating and food-related behaviours that are a component that resonates witht the symptoms of bulimia nervosa or anorexia nervosa

Food Aversion and OCD: The Diagnostic Challenge

Obsessive Compulsive Disorder can be simply understood by breaking it down into obsessions and compulsions. Obsessions, are intrusive thoughts that lead to anxiety, and to get rid of the anxiety, people indulge in rituals or behaviours— compulsions, repetitive actions that are meant to reduce the anxiety these thoughts generate.

Individuals with OCD often tend to create ‘rituals’ around the preparation, eating, or avoiding specific food due to anxiety about choking, contamination, or other concerns. They might, for instance, wash their food obsessively, have rigid guidelines for meal preparation, or completely avoid particular foods.

These actions can be similar to food aversion, where the avoidance is mostly caused due to sensory problems or a dread of the unfavourable effects of particular foods. However, ARFID is primarily diagnosed due to refusal or avoidance of food due to sensory characteristics, which might not include any ritualistic behavior around it.

The fundamental differentiator is in the underlying cause: in OCD, compulsive behaviours and obsessive thoughts are the sources of avoidance and these rituals. On the other hand, sensory sensitivity or unpleasant eating encounters in the past are usually the main cause of food aversion.

Nevertheless, this difference might be subtle and challenging to observe, particularly when there is a comorbidity in the person's reported experiences.

Furthermore, eating disorders like anorexia nervosa and ARFID (Avoidant/Restrictive Food Intake Disorder) might show several other complications when OCD is comorbid. The impact of OCD on eating habits might bear a resemblance to the symptoms of eating disorders. To determine if the main problem is OCD with food-related compulsions or an eating disorder, this overlap needs a proper assessment by a professional.

Repetitive Refrigerator Checking: Rather than being concerned about missing objects, an OCD sufferer may check the refrigerator frequently to make sure food items are not contaminated. This behaviour is motivated by anxieties about bacteria or germs.

Eating in Public: An OCD sufferer may refrain from eating in public because of severe concerns about contamination or germs. Instead of worrying about other people's opinions, they may prioritise food safety and environmental hygiene.

Throwing Out Food: Rather than limiting calories, an OCD sufferer may often throw out food long in advance of its expiration date out of concern that it has rotted or is hazardous to eat, even in the absence of any visible evidence of deterioration.

Excessive Hand Washing: Rather than because of a general concern for hygiene, an OCD sufferer may wash their hands excessively after eating in an attempt to eliminate any oils, fats, or residues that they believe to be there. This behavior is motivated by the need to feel clean and uncontaminated.

ARFID and OCD: The Overlap

It can be difficult to differentiate between ARFID and OCD-driven food avoidance due to the similarity of these behaviours, particularly when there are overlaps in the concerns and rituals related to eating. Moreover, these avoidance tendencies can lead to weight loss, dietary inadequacies, and difficulties with day-to-day functioning in both diseases.

Differentiating the Disorders Using Diagnostic Criteria (DSM-5)

OCD:

Obsessions (unwanted, intrusive thoughts) and/or compulsions (repetitive actions or mental exercises done to calm anxiety) are present.
Fears of injury, pollution, or other disastrous consequences are common in obsessions.
Behaviours to reduce stress caused due to these obsessive thoughts, for example, repetitive washing, checking, or re-organizing habits.

OCD with ARFID:

Certain food avoidance behaviours are a result of intrusive thoughts specifically about contamination or other food-related anxieties.
Concerns about one's weight or body image are not motivated due to avoidance.
severe malnutrition, loss of weight, or disruption of regular growth and development are the results observed due to these obsessions.
social connections and everyday functioning are severely impacted as a result of the need to follow rigid food-related patterns.

Data on the Prevalence of Co-Occurring OCD and ARFID:-

Worldwide Data: Studies reveal that a sizable fraction of people with ARFID also have co-occurring OCD; estimates place the number of people with ARFID who may have an OCD diagnosis at between 20 and 30 per cent (Kambanis, PE., et al., 2019).

Indian Statistics: Although there is less data specifically for India, research shows that there is a notable overlap in the prevalence of OCD among those who have eating disorders, such as ARFID. These data are hereby consistent with global trends.

Effects of OCD and ARFID on Everyday Life

OCD has a strong effect on food-related anxieties and avoidance behaviours as discussed in several studies. This can have a major impact on appetite and overall body growth. Their general health and nutritional intake may be impacted by this phobia, which may cause them to restrict their food, etc. It might be difficult for people to enjoy meals or keep up with a healthy balanced diet.

It can be difficult to eat in social situations, share meals with people, and have a positive relationship with food when dealing with chronic anxiety and avoidance. Moreover, the weight loss or increase, nutritional deficiencies, and physical health issues that can arise from a restricted diet over time can exacerbate the negative effects on general health.

Obsessive thoughts about vomiting or stomach discomfort after eating are common in OCD patients. These beliefs cause great anxiety and discomfort. An individual may, for example, worry that particular food could be contaminated or not good for them, and consuming it will cause them to get ill, even when there is no proof or past experience to back up these worries.

Compulsive actions intended to lower the perceived risk, such as avoiding particular foods or performing patterns before, during,or after meals might be the cause of these obsessive thoughts. These patterns can involve overeating, chopping food into tiny bits, washing them rigorously, or using certain cutlery that is thought to lessen the unpleasant consequences. People with OCD use these compulsions as a short-term way to cope with their fear, which reinforces the thought cycle of obsession and compulsion.

Treatment Options for ARFID and OCD

Effective management of co-occurring ARFID and OCD requires a holistic approach that includes mental health therapy, pediatric responsive eating therapy, dietician assistance, and maybe medication. Tailored therapies are designed to help people with these complicated diseases feel less anxious, eat better, and live better overall.

Cognitive Behavior Therapy:

Cognitive Behavior Therapy is an effective treatment option for ARFID (Dumont, E., et al., 2019). Preventing the typical avoidance responses entails exposing people to fearful events or foods gradually while detecting and challenging negative thought patterns (also known as exposure and response prevention, or ERP).

Children with ARFID and Responsive Feeding Therapy (RFT):

RFT is a unique method created to help children with ARFID who have feeding issues (Wong G., 2018). Through planned, enjoyable mealtime experiences and reinforcement of proper eating behaviours, it focuses on gradually increasing the type and quantity of foods a kid will eat.

Dietician Support:

Dietician support is a crucial element of the treatment. Dieticians work with individuals to create customised meal plans that aim at catering to nutritional deficits and inculcating healthy eating habits. They also educate the individual on food variety, portion sizes, ways to enhance caloric intake, and other education and strategies that help people make up for the deficit caused by the disorder.

Pharmacotherapy:

Although medicine does not directly treat ARFID, it can help control the symptoms of co-occurring disorders like OCD. SSRIs are frequently administered to help lessen obsessive behaviours and thoughts (Issari, Y., et al, 2016).

Coping Strategies for ARFID and OCD

Along with a professionally customised intervention plan, self-help techniques can be used for OCD (Obsessive-Compulsive Disorder) and ARFID (Avoidant/Restrictive Food Intake Disorder), giving them more tools to control their symptoms. Together with counselling and medical assistance, these techniques can enable people to take an active participation in their own healing.

Self-Help Strategy Examples:-

Exercises for Mindfulness: By engaging in mindfulness practices, people can learn to be more objectively aware of their thoughts, feelings, and physical experiences. Exercises that promote mindfulness, including mindful eating, can lessen anxiety during mealtimes and increase awareness of food choices.

Relaxation Methods: Methods like progressive muscle relaxation or deep breathing exercises can help reduce tension and anxiety brought on by OCD symptoms or concerns related to food. These methods encourage calmness and can be applied when feeling very anxious or distressed.

Keeping a Food Journal: Maintaining a food journal can assist people in tracking their eating behaviours, recognizing avoidance or restriction patterns, and tracking their improvement over time. This self-monitoring tool can help identify anxiety triggers and make treatment sessions with medical professionals easier.

Conclusion

With the right care and assistance, patients with OCD (Obsessive-Compulsive Disorder) and ARFID (Avoidant/Restrictive Food Intake Disorder) can manage the condition and recover. Significant progress toward better health and quality of life can be made with comprehensive interventions catered to each patient's needs.

Additionally, through the integration of these strategies into everyday routines, people can develop the ability to handle anxiety, enhance their eating habits, and promote a more positive connection with food using both professional help and self-work.

Furthermore, effective treatment requires seeking assistance from licensed mental health providers. Treatments for the underlying causes of ARFID and OCD include cognitive behavioural therapy (CBT), responsive feeding therapy (RFT), and/ or medication. These approaches offer methods for controlling anxiety, enhancing eating habits, managing symptoms, and advancing healing using professional help in a safe environment.

References

Bardone-Cone AM, Wonderlich SA, Frost RO, Bulik CM, Mitchell JE, Uppala S, Simonich H. Perfectionism and eating disorders: current status and future directions. Clinical Psychology Review. 2007;27(3):384–405.

Coglan, L., & Otasowie, J. (2019). Avoidant/restrictive food intake disorder: what do we know so far?. BJPsych Advances, 25(2), 90-98.

Dumont E, Jansen A, Kroes D, de Haan E, Mulkens S. A new cognitive behavior therapy for adolescents with avoidant/restrictive food intake disorder in a day treatment setting: A clinical case series. Int J Eat Disord. 2019 Apr;52(4):447-458. doi: 10.1002/eat.23053. Epub 2019 Feb 25. PMID: 30805969; PMCID: PMC6593777.

Issari Y, Jakubovski E, Bartley CA, Pittenger C, Bloch MH. Early onset of response with selective serotonin reuptake inhibitors in obsessive-compulsive disorder: a meta-analysis. J Clin Psychiatry. 2016 May;77(5):e605-11. doi: 10.4088/JCP.14r09758. PMID: 27249090.

Kambanis PE, Kuhnle MC, Wons OB, Jo JH, Keshishian AC, Hauser K, Becker KR, Franko DL, Misra M, Micali N, Lawson EA, Eddy KT, Thomas JJ. Prevalence and correlates of psychiatric comorbidities in children and adolescents with full and subthreshold avoidant/restrictive food intake disorder. Int J Eat Disord. 2020 Feb;53(2):256-265. doi: 10.1002/eat.23191. Epub 2019 Nov 8. PMID: 31702051; PMCID: PMC7028456.

MacDonald, D. E., Liebman, R., & Trottier, K. (2024). Clinical characteristics, treatment course and outcome of adults treated for avoidant/restrictive food intake disorder (ARFID) at a tertiary care eating disorders program. Journal of Eating Disorders, 12(1), 15.

Rothenberg, A. (1986). Eating disorder as a modern obsessive-compulsive syndrome. Psychiatry, 49(1), 45-53.

Wong G, Rowel K. Understanding ARFID Part II: Responsive Feeding and Treatment Approaches National Eating Disorder Information Centre - Bulletin. 2018;33(4).