Eating behaviours as a by-product of OCD.

Although eating behaviours were not always the primary presenting issue, many adults reported that their eating was directly affected by their OC symptoms.

In terms of the contamination, it has influenced what I eat… I’ve cut out things at times due to whatever was in the news (H)

If I thought I had any red on my plate, I would associate that as being something to do with blood and that it was contaminated, and I couldn’t eat it. (B)

[The OCD] routines transfer into other parts of life. So, if I’m preparing food, I have to do it in a certain way. (G)

Moreover, participant E felt that she experienced more atypical eating behaviours when her OC symptoms were more severe: “I would say definitely when my OCD is in general, more stressful, I have a lot more symptoms and then some of those symptoms are like the eating ones”.

In cases of low mood or milder distress, participants would report more overeating as a form of comfort. However, when participants felt intense anxiety or distress, they were more likely to undereat.

I think if I’m really distressed, it’s like you forget food. But if I’m like, just kind of low, I hit [sugary foods and drinks] like an alcoholic hitting the bottle (C)

Similarly, participant D distinguished between when she would use eating as a form of comfort, and when she would be less likely to want to eat due to feeling distressed:

If I’m stressed and I don’t know what to do with myself, or if I’m feeling guilty or particularly worried about something and a bit restless, then I probably want to eat. But, if I’m tired and frustrated, and maybe more tearful, then maybe I’d be less inclined to eat (D)

It’s not always as it seems.

Another commonality among participants was that their difficulties with eating were not always visible. Subsequently, this may have prevented others, or even themselves, from identifying issues with their eating behaviours or diet. For example, participant H would receive compliments on her appearance, despite her weight loss being driven by her OC symptoms: “lots of people would comment on it and they think oh, you look great, but I’m actually really unwell”.

Similarly, participant C described her appearance as fit and healthy, despite acknowledging that her diet was restricted and largely consisted of sugary foods and drinks: “If someone looked at me, they would think I was fit and healthy”.

Some participants mentioned that their perceived balanced or healthy diet may have masked their actual challenges with eating:

I try to keep it balanced somehow … but at the same time it’s restricted because the only way it finds the balance is through me doing everything in the background to freeze everything or to buy everything that’s got really long dates (G)

Another participant, B, suspected that she had symptoms of an eating disorder, but she perceived these to be less serious as her diet was healthy:

Sometimes I think I have a borderline eating disorder issue. It’s not like out of control because I eat a healthy diet and I’m not unwell (B)

Lack of support for eating.

Most participants felt that they did not receive support for their eating difficulties, despite expressing their challenges to healthcare professionals. For example, G, who had a history of an eating disorder, described how her thoughts about her eating behaviours were not considered:

I only came to the conclusion that [my eating] was linked to OCD myself. I had to figure everything out myself. I had to put all the puzzle pieces together myself. It was really confusing and distressing to do so. But even when I did, they still didn’t listen to me, and they still didn’t even offer me different care or consideration when treating me (G)

Another participant also described concerns about her weight, but reported a lack of support from healthcare professionals:

When I started with my psychiatrist, I was very self-conscious of losing a lot of weight and it would have been something I would have probably brought up more than being asked, but I didn’t get any support around it (H)

Participant K, who suspected that she had an eating disorder during adolescence, also felt that her difficulties with eating were unsupported by healthcare professionals. She suggested a necessity for healthcare professionals to understand how OCD affects individuals beyond their primary OC symptoms and to understand how the patterns of OCD may be linked to pathological eating patterns:

What I’d really want them to think about is not just what’s presented in front of them in that moment, but to consider how some of these other things and the thinking patterns and the mental processes behind them could actually be quite similar (K)

Participant L, who self-identified as having binge-eating disorder, had previously sought support for her eating behaviours, but was told that she had already received a similar treatment for OCD. She also reported being told that the eating disorders service would not be able to support her as her BMI was in the high category:

I did ask them specifically about the eating disorders pathway and if that’s something I could access for binge-eating disorder. They said the treatment would be [cognitive behavioural therapy] and you’ve had [cognitive behavioural therapy]… I did specifically inquire about eating disorder services, but I was told that the eating disorders services were only for people with low BMI and not those with high BMI (L)

In the few cases where support was provided, participants felt disappointed that it did not consider the effect that OCD has on eating. For example, J, who is of low weight and has a limited diet due to fears of contamination and emetophobia, was referred to a dietician who suggested that adding more calorie dense products to her food would help her gain weight. However, J would have preferred support which helped her to navigate difficulties with food preparation and eating: “I was referred to a dietician actually and I didn’t find it helpful at all”.

I’ve had all sorts of [diabetes] education, but I have a problem with preparing [food]. I know it’s unhealthy to eat processed foods and ready meals, but I haven’t managed to overcome food preparation (L)

Compensatory control.

Participants’ eating behaviours were often adopted as a method of creating a sense of safety, stability, and connection in the present moment, especially when things felt overwhelming, chaotic, or uncertain. Some participants, such as participant A, described that she would resort to safe food during times of distress: “If I’m very stressed or if I’m feeling very anxious, I do have certain foods that I’ll go back to”.

For some, specific routines around food provided them with a sense of consistency during uncertain times. For example, participant F reported wanting to eat the same foods when her grandmother was in hospital: “every single day after that I really wanted that one meal every single day just to form a bit of a routine”.

Some participants also tried to control and prevent the negative consequences of eating, which included vomiting or becoming unwell. For example, A would eat small bites of food to avoid choking: “I’d take really small bites, like microscopic. That’s why it would take me so long to eat. I just was so scared of choking”.

Compensatory behaviours, such as restrictive dieting commonly observed in eating disorders, were also noted by a few participants. For example, B described feelings of disgust after eating something she perceived to be fattening and had the urge to control this by restricting later meals.

I just kept feeling really disgusted that I just sat and ate that. I would also feel really fat. I’d probably be thinking of the next meal and how I’m going to compensate for having eaten that (B)

In contrast, E explained that her eating behaviours were not used to compensate for weight gain. Rather, she described that eating behaviours were something she could gain control over to provide a sense of security:

I’ve teetered on the edge of having eating symptoms and stuff, it’s not because I think I’m going to get fat or anything. It’s because it’s just something that I can very easily control (E)

Maladaptive attempts at stability.

Whilst some participants used their eating behaviours as a method of providing some certainty, some acknowledged that the restrictions posed by their OC symptoms led them to lose control of their eating behaviours. Participant J explained that her OCD rituals concerning food preparation were initially used to gain control over becoming unwell, but recognised that these rituals were controlling her instead: “You take all these steps to make sure you do have control, but actually, if you think about it, the OCD is controlling me”.

She further described closely monitoring the pace of eating, due to fears of becoming unwell, illustrating how attempts to maintain control could become restrictive:

I have to watch the clock to see what time it was when I started eating to when I finish. I’ll go slower if I feel like I’m eating too quickly, because the worry is if I eat too quickly, I’ll be sick. (J)

Similarly, G described that she was unable to deviate from set routines involving food and meal preparation, indicating that she could not control her thoughts and compulsions:

I’m not just restricted by the type of food I eat or how I eat and things like that, I’m also restricted by time. So physically my body, my anxiety will not let me eat after 7:00 o’clock in the evening. Because for no reason whatsoever, 7:00 PM, even a second past, even 7:00 PM on the dot, I can’t eat past 7:00 PM. (G)

Participant K noted that her desire to have a consistent eating routine was driven by anxiety. She did not want to miss her meals as this could lead to feeling a lack of control, which she found stressful:

I can get quite anxious if I miss a meal as well. I find that really stressful. I don’t quite know what I think’s going to happen. (K)

Participant C also described that her eating behaviours were not controlled: “I’ve got an addiction and it’s hard to stop it”.

Effects on daily living.

Many of the participants reported that the impact of OCD on their eating also came with negative effects on their daily lives. For K, her obsessive symptoms led her to have increased structure around her daily eating routines:

I can remember my day becoming structured around when I was going to be able to have something to eat and what that was going to be, and how I was going to avoid a situation where I might have to veer from that structure. (K)

Some participants also noted that not only did their OCD have a negative impact on food preparation and dietary intake, but also recreational activities concerning food. For example, B stopped baking: “I never thought that I would be able to bake again because of the thoughts I had to do with contamination of food”. Participant J engaged in reassurance seeking behaviours during food preparation as she questioned whether she would become unwell from undercooked food:

I do seek a lot of reassurance as well when I’m cooking or when I’m eating food. I will ask, does this look right? Does this taste right? Are you sure this is cooked properly? How long did you cook it for? And then I’ll ask again. Will this make me ill? (J)

Similarly, participant L’s cleaning obsessions made it difficult for her to use the kitchen, which meant that she was unable to cook healthy and nutritious meals. Consequently, she often resorted to processed foods which she acknowledged were not ideal for her health:

I don’t actually like [ready meals and processed foods], it’s just the convenience of having it and the difficulty I have with making other types of food. If I prepare my own food, I have to sanitize the work surfaces, I’ll have to clean the utensils and clean the kitchen and put them away afterwards. It’s so exhausting, and then you have to deal with the leftovers (L)

Some participants also felt guilty that their difficulties with OCD and eating had a negative impact on those around them:

It doesn’t just affect me, but also the people around me. That brings on a lot of guilt and, in turn, just makes the routines more restrictive because I want to protect the people around me. But, it’s restricting them. (G)

It’s not just impacting me, but others around me, which is really sad. My husband gets really anxious cooking because he doesn’t know if I’m going to eat it or not, so now he carries out safety behaviours by overcooking food. (J)

Eating outside of the home.

Eating outside of the home was further complicated by OCD, with many participants expressing concern around feeling unsafe outside of the controlled home environment. For example, participant A, who experienced eating difficulties from a young age, felt that she was unable to challenge her obsessions when eating outside of home: “At home obviously it’s a very safe environment for me to challenge myself in, whereas outside it’s not always”.

Similarly, participants described feeling anxious when eating out and would often try to find ways to make the situation safe out of fear of feeling unwell:

Even if I was going out with my friends or something, I wouldn’t have been able to. Even if we were going out for pizza, it would have been really stressful. I would have been thinking about what I could do to try and make it safe for me (K)

Eating out somewhere new fills me with anxiety, because if someone’s not recommended it, it’s that thought of ‘what if I get food poisoning?’ So, before I go out to a restaurant, I will look at their hygiene rating and then if it’s a four or five, I’ll be like okay, that’s fine. (J)

For G, eating outside of the home caused much distress, leading her to engage in checking behaviours to ensure her environment was clean. Although she recognised that this was not socially appropriate, she would often be unaware of doing this as it became habitual:

I’m on really high alert and I check everything around me… even unconsciously, if I walk into someone else’s kitchen, I will impulsively just check around the kitchen to make sure everything’s clean…I know that it probably seems really rude and invasive, but I can’t help it and a lot of the time I don’t notice I’m doing it because I’m so used to doing it at home for myself. (G)

In contrast, some participants enjoyed eating outside of the home as it provided a distraction from their OCD thoughts. Participant L, who had difficulties with preparing food, liked to eat out as she would not need to worry about cleaning up: “If you eat out you don’t have to worry about washing up”.

I find it distracts me from the OCD and that the OCD voice is a lot quieter because there’s other voices [socialising noise] in the room. I wouldn’t avoid socialising for food or anything like that, I’d quite enjoy going to a restaurant (D)

Life through the lens of OCD.

Some participants offered an explanation as to why OCD impacted their daily lives and eating behaviours. They described that their perceptions of the world were altered by their OCD, which led them to doubt reality and question things that someone without OCD would not. For example, L recognised that her difficulties using the kitchen were constrained by rigid rules which she had to follow, whereas this may not be an issue for someone without OCD:

A person without OCD would be like okay, this is what they recommend for food hygiene purposes, and this is what I can manage – they can take the advice within reason, but it just gets a bit blurred with my OCD (L)

Participant G also felt that her perceptions of reality were skewed by OCD. Although she recognised that her thoughts may be irrational, she could not escape the doubts:

Realistically, I know it’s a professional chef in a clean kitchen. Otherwise, the restaurant would be shut down, but in the little OCD corner of my brain, it just finds so many excuses to tell me that I’m in danger or that it’s going to make me unwell, or it will make me anxious so that I feel nauseous and stop eating. (G)

Similarly, J described her dread of mealtimes as she was never sure what compulsion she would have to carry out to feel safer around food, “Every mealtime you dread, because I can’t say what my brain is going to start telling me what I need to do.”

Whilst F reported very few atypical eating behaviours herself, she provided insight as to why those with OCD might have difficulties around food, “If [those with OCD] struggle with eating, it’s probably due to a compulsion or intrusive thoughts.”