Eating Disorder vs OCD: How to Tell Them Apart and Why It Matters (with Guilia Suro) | Ep. 435

In this episode, Kimberley Quinlan and Dr. Giulia Suro unpack the overlapping features of OCD and eating disorders, helping you understand how to tell them apart, how they interact, and how to treat them effectively.

What you’ll learn in this episode:

• How to tell the difference between OCD and eating disorder thoughts (and why it matters for treatment)

• Why some compulsive food behaviors aren’t actually about food

• What ego-syntonic vs. ego-dystonic thoughts reveal about your condition

• How exposure therapy and ACT can be adapted for both OCD and eating disorders

• Why full recovery is possible—even if you’re struggling with both diagnoses

• What clinicians often miss in assessment (and how to get the care you truly need)

OCD vs. Eating Disorders: How to Tell the Difference and What to Do About It

When your struggles with food, weight, or intrusive thoughts start to overlap, it can be difficult to know what’s really going on. Is it OCD? An eating disorder? Or both?

In this episode of Your Anxiety Toolkit, Kimberley Quinlan sits down with clinical psychologist Dr. Giulia Suro to unpack the overlap between Obsessive Compulsive Disorder (OCD) and eating disorders. They explore how to tell them apart, how they interact, and—most importantly—how to move forward in recovery.

Why It Matters: Diagnosis Impacts Treatment

Untangling OCD from an eating disorder isn’t just about labeling—it’s about understanding what’s driving the behavior. Both conditions can involve obsessive thinking, rigid rules, and compulsive behaviors, but the why behind them is often different. That difference is crucial because it changes how treatment should be approached.

“If we’re engaging in compulsions with food out of a fear of weight gain, that’s going to look very different than someone who fears eating meat will make their parents sick,” explains Dr. Suro.

What’s the Difference Between OCD and an Eating Disorder?

One of the key ways clinicians distinguish OCD from an eating disorder is by looking at whether the thoughts are ego-syntonic or ego-dystonic:

• Eating disorder thoughts tend to feel right or in line with your values (ego-syntonic). For example, “If I eat less, I’m being good.”

• OCD thoughts, on the other hand, feel intrusive and unwanted (ego-dystonic). These might sound like, “If I don’t chew this food the right number of times, something bad will happen.”

This distinction is subtle but powerful.

Shared Symptoms, Different Roots

Both conditions can involve:

• Food rituals (cutting food a certain way, only eating at certain times)

• Avoidance (fear of contamination or fear of gaining weight)

• Obsessive thoughts (preoccupation with calories, body size, or harm)

But the underlying fear driving those behaviors—and whether or not the person wants those thoughts—can signal whether it’s OCD, an eating disorder, or both.

What Does Treatment Look Like for Each?

The good news? Exposure-based therapies work well for both conditions, even if they look a bit different in each case.

OCD Treatment:

• Exposure and Response Prevention (ERP): Facing feared situations (like eating without washing hands) and resisting the urge to do compulsions.

• ACT (Acceptance and Commitment Therapy): Learning to defuse from thoughts and lean into values-based behavior despite discomfort.

Eating Disorder Treatment:

• Food exposures: Gradually reintroducing fear foods in a supported environment.

• Values work: Challenging societal messages about thinness and self-worth.

• Nutritional rehabilitation: Relearning what normal, nourishing eating looks like.

• Holistic care: Including trauma work or family therapy if needed.

“For me, the first step was realizing that the beliefs I held about my body weren’t facts,” says Kimberley. “I had to unlearn so much messaging.”

Managing Both: Yes, It’s Possible

If you’re struggling with both OCD and an eating disorder, treatment can feel overwhelming—but you’re not alone. Many people deal with both, and with the right care, recovery is absolutely possible.

Tips for managing both:

• Use exposure therapy creatively. Mix OCD triggers with food challenges when appropriate. For example, eating in a public place without washing hands.

• Lean into values. What do you want life to look like beyond OCD or an eating disorder?

• Seek integrated support. This may include a therapist, dietitian, and medical provider.

“Recovery from both is 100% possible,” Dr. Suro encourages. “Don’t settle for just surviving. You deserve full recovery.”

Watch Out for These Common Misconceptions

• “You have to be underweight to have an eating disorder.” False. Most people with eating disorders fall within a ‘normal’ or larger body size.

• “OCD is just about hand-washing and perfectionism.” Nope. It can include mental compulsions, religious fears, and more.

• “You have to treat the eating disorder before you can treat OCD (or vice versa).” Newer research shows that concurrent treatment is not only possible—it’s often the most effective approach.

A Note for Clinicians

Guilia Suro encourages clinicians to:

• Always screen for OCD when treating eating disorders (and vice versa).

• Use tools like the Y-BOCS (Yale-Brown Obsessive Compulsive Scale) and Eating Disorder Inventory to guide assessment.

• Understand the importance of team-based care when possible—especially when time is limited.

“We don’t need to pick one diagnosis to work on first. We can look at the thoughts, the rigidity, the compulsions, and treat them holistically.”

Final Thoughts: Hope for Healing

If you’ve been feeling stuck, overwhelmed, or unsure which direction to take, know this: you can heal.

You’re not broken. You’re navigating complex thoughts and experiences—and with the right support, you can move toward peace, freedom, and a life that aligns with your values.

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Transcription: Eating Disorder vs OCD: How to Tell Them Apart and Why It Matters (with Guilia Suro) 

Kimberley:

If you’ve ever found yourself questioning, is it OCD or is this an eating disorder? You are not alone. The struggle of untangling eating disorders versus OCD can feel confusing and overwhelming, especially when your thoughts and behaviors overlap. In today’s episode, I’m joined by Giulia SRO to bring clarity, exploring the differences and surprising similarities and what all that means for you, whether you’re trying to understand your own experience or you’re looking for practical steps towards recovery, this conversation is designed to help you find answers and hope. So let’s dive in and make sense of what you’re going through. Welcome, Giulia.

Giulia:

Thank you so much for having me. I’m really excited to be here.

Kimberley:

Yes, I’m so thrilled actually, it’s so wonderful that you had reached out to me because this is actually a question we get a lot and one that I’d like to cover a little more here in the future. So when I, today, well actually Theo is here too, as he always is for the podcast. These days, we’re really wanting to understand the differences between eating disorders versus OCD. Why is that so important for the diagnosis and treatment of people?

Giulia:

Well, I think getting at sort of the underpinnings, particularly the obsessions and what’s driving them can be really helpful in informing an effective treatment plan. So there’s lots of ways that food can get tangled up in obsessive thinking and compulsions and rigidity in rules and all the things we’re going to talk about. But if we’re engaging in compulsion with food, whether it’s counting or tracking or restricting certain food groups because we have fear of losing control of our bodies or a fear of gaining weight, the treatment could look really different than if we have fear of eating meat that we haven’t seen prepared because we believe it will offend God or our parents will get sick or something like that. So we really want to be that curious observer and understand what is driving some of the obsessive thoughts and the compulsions that are coming into play to regulate the distress around them.

Kimberley:

Amazing. For somebody who’s presenting with some of these behaviors, how might we differentiate the difference between whether it’s specifically OCD, what would that look like compared to an eating disorder? And then I will actually, after you explain it, I’ll actually share a personal experience that I had as well.

Giulia:

Oh, cool. Okay. I might speak out of every side of my mouth in this part because I think diagnostic criteria can be helpful if it’s serving to get us to the treatment that we need. And also I think these diagnostic criteria can be incredibly unhelpful. We know there’s a lot of overlap and as much as 40% of people who have an eating disorder also have co-occurring OCD for OCD, it’s like 20% have an eating disorder. So there’s a lot at play, and most people who have an eating disorder have another co-occurring diagnosis, whether it’s OCD or PTSD or an anxiety disorder. So there’s a lot going on. I actually really like to take what’s called a trans diagnostic approach and not focus so much on like, oh, that’s an obsessive thought that belongs in the OCD pile. That’s a compulsive behavior that belongs in the eating disorder pile.

And really just look at your brain, the way your mind is working, what’s helpful, what’s unhelpful, what behaviors are working for you, what’s not, what do we want to change? This is very much informed by acceptance and commitment therapy, which I’ve spoken to you about before. However, I think one thing that really distinguishes eating disorders from OCD in terms of the cognitions is the thoughts that come up in the context of an eating disorder tend to be eco syntonic, meaning they are consistent with our currently held views or values, good or bad. So in our society, restricting our diet to lose weight or trying to change our body is something that is socially acceptable. And so having thoughts that I am good if I do that matches or it can with OCD, the thoughts are often intrusive. They’re ego dystonic, meaning we don’t want to be there. We don’t want them to be there. They’re not consistent with our values and our sense of self. They can be scary and frightening.

Kimberley:

Absolutely. Absolutely. And I will share, as someone who suffered with an eating disorder, it was very in line with my values. I believed it to be true that in those days that it would be bad if I gained weight and that I would do anything. I would do a lot of what seems like just regular daily compulsions, but I was doing them because I was terrified of my body changing.

Giulia:

Yeah, absolutely. I think that’s an really important point. Having a fixation on food or preoccupation with food or weight loss is pretty much normalized in our society and also tracking food, engaging in ritualistic food behaviors, they might not be described that way, is also sort of normalized. So it’s tough to parse out when all of the messages that we’re receiving from our society is telling us this is the right thing to do, look better, feel better. We could spend a lot of time talking about orthorexia as well as obsessive compulsive personality disorder, which tends to be more egosyntonic. The thoughts aren’t as frightening or intrusive. It’s more around rigidity and perfectionism, which can get totally played out with clean eating, healthy eating, pure, things like that.

Kimberley:

So interestingly for the listeners is I totally put Giulia on the spot today because we were going to talk about food related obsessions, and then I totally was like, we’re changing it. Can we change it? So thank you for being so flexible. It’s important. There’s a lot to talk about, but just briefly, a food related obsession. You’d mentioned contamination. What are some of the behaviors people do when they have OCD around food

Giulia:

OCD around food specifically? I think some of the behaviors can look like a lot of tracking, counting, keeping meticulous logs, a caloric count that you can’t go over. That’s sort of arbitrary. I remember having a client years ago that it was like, this week it’s 1300. Next week it’s 1600 without any sort of rhymer reason, but there’s this profound sense that if I go over that, something bad will happen. So get tied up with morality or that sort of scrupulosity eating this food makes me a bad person. And so all of a sudden we have sort of these good foods and bad foods and we start to architect our life around them discussed. I also years ago, had a client who had a lot of contamination obsessions, and so working with raw meat, eating meat that wasn’t prepared in a very specific way or cooked in a very specific way became really problematic and distressing. And that started to generalize to other types of food.

Kimberley:

Absolutely. Absolutely. And to add to that, I’ve had examples of clients where it was just around symmetry, right? That food needed to be symmetrical or it couldn’t touch each other for contamination reasons, or they had to have the right thought when they swallowed a food. So they would be pushing the food around and parents would immediately take ’em to an eating disorder specialist thinking that that’s what was going on. But this person is having this whole inner turmoil of having the right thought and so forth.

Giulia:

Yes, yes. That just Right. So thank you for bringing that up. The way the food is presented, what it’s touching on the plate, the number of times we have to cut it up or chew the number of bites we take, these can all be enormously distressing behaviors that get tied up with the food.

Kimberley:

Yeah, and I think that going back to the first thing, I think that’s why it’s so important that we do pass apart what, because the treatments are different. Let’s use that as a segue. So how does therapy for OCD differ from therapy with an eating disorder?

Giulia:

Well, the good news is there’s a lot of commonalities, so exposure is going to be a part of it. We know that exposure response prevention remains the frontline treatment for OCD, and I think that whether it’s an official version or not is really important. When we’re working towards eating disorder recovery, we cannot get around eating. And the path towards eating disorder recovery is having a more intuitive, trusting relationship with food, which means eating again and again and again, and practicing sort of letting go, the fears, the control, the rigidity that takes place with an eating disorder. I think because there’s so many parts at play and there might be other co-occurring diagnoses, it can also be really important to take a more holistic approach in addition to the exposure work. So doing family-based work, potentially trauma-focused work, a lot of relapse prevention. Again, I’m a big proponent of act cognitive behavioral therapy also remains a gold standard

Kimberley:

For me. The first part of eating disorder treatment was slowing down, particularly, it was a belief. I think I had been trained as societally to believe that I needed to be thin and that it was better to be thin and all these other very distorted beliefs. The first part was actually just being able to identify that wasn’t true, that wasn’t a fact, is probably the best thing that society had maybe pushed that onto me. And there were newer other ways of thinking, which kind of blew my mind.

Giulia:

I think that’s brilliant, and that can be tough to get to. It might sound sort of sense. It makes sense to the people listening, but for someone with an eating disorder, that is a huge leap. I really believe recovering from an eating disorder in our society requires this massive leap of faith because we’re asking you to challenge so much messaging that we’re just spoonfed from every angle around what our bodies should look like are worth based on our bodies, what a regular eater looks like, what a lunch should look like, a dinner, et cetera, et cetera. When we eat dessert, when we don’t, how we express our emotions in relation to food, all that stuff. So that’s not a small thing

Kimberley:

For sure. And just to sort of back you too is there was a huge component of exposure therapy in my treatment, but it was never called that, never once did we call it ERP. It was more we would call them experiments or it would be more, are you willing to try this? Are you willing to try that? And that was pretty terrifying, especially because you’ve still held those beliefs even though you’re a beginning to challenge them.

Giulia:

Yeah, absolutely. It’s why I think for anyone out there who’s struggling with an eating disorder or thinks they might be and is in therapy or working with a dietician, asking about doing food exposures in session or again, that’s a very technical term, but just eating with else in a controlled safe setting, it can be a really, really good opportunity to practice some of the fear foods that might be on your list or using things spreading some peanut butter without a measuring spoon, whatever those challenges are around control or rigidity, having sort of a safe place to do that.

Kimberley:

For sure, for sure. So we’ve talked a little about the differences between the presentation of food related OCD compared to an eating disorder, and of course there are different types of eating disorders too, which we won’t have enough time to go into completely. But what are the signs that someone might be dealing with both or how would somebody identify that they are dealing with both? What would that look like?

Giulia:

Sure. So what we know is that of the different eating disorder diagnoses that exist, which are problematic, but it’s what we have. OCD tends to be most common with the diagnoses that have a restriction component. That could be anorexia nervosa, restricting type or binge PGE type as well as arfid and restriction can also be present with binge eating and bulimia of course, but we know it’s when there’s that sort of rigidity, control fixation, rule-based thinking and behaviors around food that could be a red flag that there might be a co-occurring presence of OCD.

Kimberley:

Yeah, I think that’s where it’s really interesting too, because some of my patients with OCD and an eating disorder, so when they have both have used, I’m just curious to hear thoughts on this, have used restriction as almost a form of punishing themselves. Is that something that you have seen in your practice or as a form of holding back any kind of pleasure or anything nice for themselves? Is that something you see?

Giulia:

Yeah, absolutely. So there’s a assessment tool that’s used to sort of measure the different underlying drivers of eating disorder behaviors called the eating disorder inventory. And one of the scales is called asceticism, and it sort of has an interesting history I won’t get into, but there was a cluster of nuns, I think in the 17th century that starved themselves as a sign of devotion to God. And so it’s this act of real self deprivation. At some points, it can be real punishment that’s guilt driven. You don’t deserve to eat, but in other places it’s just, I’m better if I experience less pleasure. And we see that with food eating, but also across the board. So this might be the client that won’t spend money to get their hair cut, that won’t buy clothes for themselves when they need them, that their hygiene might be a bit poor, sort of this punishment, self deprivation across the board.

Kimberley:

Right, exactly. Let’s say somebody does have both and how might they manage that effectively? And the reason, what I will also say, and maybe you can speak to this is often in my practice, I’m the person working on the eating disorder or the OCD or both. Sometimes I’m working in communication with another clinician. Let’s say the other clinician is working on the eating disorder and I’m doing the OCD. We find this sort of whack-a-mole of the OCD goes down, but the eating disorder goes up. And then once we get the eating disorder down, maybe some other themes of OCD pop up. So how might somebody manage both of them effectively knowing that that’s not true for everybody, but can happen?

Giulia:

Yes, I have lots of thoughts about this. I think what the evidence shows is when there are really two true distinct diagnoses of OCD that might be contamination or just right or whatever it is, plus an eating disorder, and they’re really different and they play out in different ways. We want to do the exposure response prevention where creating a hierarchy, but make sure that food is happening every other exposure and finding a way to tie them in. However, I’m going to make a plug for acceptance and commitment therapy here, and this is why I really love this modality in the context of eating disorders, which can often feel like a game of whack-a-mole, whether it’s OCD or substance use or self-injurious behaviors, we oftentimes when we get the eating disorder under control, and by that I mean when the behaviors have remitted distress goes up because we’ve taken away a means of self-regulation.

And so we see other things then start to pop up. ACT really focuses on those underlying processes. So a really amazing act skill act is made up of six components. They’re called the ACT eFlex. One of them is called cognitive diffusion, and it’s a skill that can be applied to any sort of type of thinking that is unhelpful. And rather than trying to challenge our thoughts, this is where it differs a bit from cognitive behavioral therapy, even though it’s definitely in the same family. Rather than trying to identify distortions and challenge them and replace our thoughts with more balanced thinking, we are using mindfulness and acceptance to notice the thoughts for what they are intrusions or that’s an eating disorder based thought, or that’s a diet culture thought and see them with some objectivity and some space, and then use that space to direct our attention into the present and engage in behaviors that are more helpful. And there’s lots of different diffusion exercises that are really easy to put into play. I’d be happy to share more or we can talk about that another time.

Kimberley:

Sure, yeah. Can you go back to how you were saying the exposure practice with eating in between? Can you elaborate a little more on what that would look like?

Giulia:

Sure. So let’s say someone has anorexia nervosa and contamination phobia. And also I’ll caveat that they are medically stable and are in a place to be doing food exposures, which if you’re in therapy for either an eating disorder or OCD, you want to make sure you’re medically stable before doing any sort of food exposure work. We might have someone, I actually remember doing this a long time ago, eat a meal in McDonald’s and we would practice doing it without washing our hands first and sort of sit with the uncertainty of what might come up around that. And we’re also challenging a fear of food. And then the next exposure might be going into that McDonald’s bathroom and drinking water from out of the sink, nothing related to food, but we’re sort of tackling more of a contamination the next exposure we might bring in food and do that in a different way, eating in a different public setting or touching the ground and the dirt and then eating with our hands, something like that. So we don’t want to lose sight of the food. We don’t want to collude with any avoidance around the food piece. We want to keep integrating that thread through the exposure work to make sure the clients are gaining momentum and working their way through the hierarchy.

Kimberley:

But that is so hard for those people speaking hard because it’s like a double whammy. You’re hitting too major fears at the same time. Often we work either in a gradual exposure way or let’s say we might take away gradual exposure and do more of an inhibitory learning approach. What would you say to someone who I am hearing my clients in my sessions just saying like, oh my gosh, the idea of doing both makes it go from easy to a 10 out of 10. Do you have any? Yes.

Giulia:

Yeah, totally. Yes. And by the way, I would not ask someone to go to McDonald’s on day one.

Kimberley:

Okay.

Giulia:

Yes, it’s true. And we do, I personally, and I think the evidence supports this, I really believe in a gentle approach to exposures. You want it to feel like a win. You want to have that high five at the end.

And I have said to my clients in the past, we are co-pilots here. I’m going to sound a bit more assertive, but this is your work. We are in it together. However, the role of exposures is to build up that self-efficacy, right? To show that you can do it, you’ve got this, you can do it. And so we want to push, and I think that’s a challenge for therapists too, to make sure we’re not sort of holding back or colluding with the client’s fears that this might be too much for them. So I always believe in understanding the comfort zone and let’s find one inch outside of it

Kimberley:

For sure. And so the last piece here when we’re discussing the contrast between OCD and an eating disorder is often, and I’ll be careful with my words here because I want this to, we have to be clear in the words we use with OCD, often people have an egodystonic obsession and that they’re pretty, they’re not certain, but often their fears are like, they’ll say, I know it’s ridiculous. I know it’s crazy, whatever their obsession is. But with eating disorders, often the rebuttal they get when it comes to exposure is the exposure probably will cause them to gain weight over time. We want them to restore themselves back to a healthy weight that they can maintain and that nourishes them. How might you approach exposure for someone with a occurring eating disorder who knows the exposure or is pretty sure the exposure will cause their biggest fear to come true.

Giulia:

Yeah, that’s great. I think really important to talk about this is where sort of preparing to do exposure work, I really believe in, I sort of call this peeling the onion around these core fears. So if I eat dessert every day for a week, I’ll gain weight. What would be so bad about that? What’s the worst thing about that? Is it the loss of control? Is it feeling shame? Is it changes in your body that you don’t think you can tolerate? Is it being in a body that was a place of trauma for you in the past? Let’s get a little bit deeper to what would be the worst possible thing about gaining weight. And now we want to walk you through the process of seeing this worst fear. I believe you could tolerate it. It might not be preferable, and I understand it’s challenging.

I always want to validate that with clients who need to gain weight as part of their eating disorder treatment, it’s not easy to gain weight in our society. That’s not a process that’s considered positive. It’s hard to see our body change when we don’t want it to. And you deserve to take the time. You need to be gentle with yourself and self-compassionate. Why we don’t want to flood you with really, really tough exposures. But we do want to show you that you can take it. And I think the process of weight restoration is a giant exposure

Kimberley:

For sure.

Giulia:

However, I do want to say most people who seek treatment for an eating disorder exist in a body that is not underweight. And they may even be in a larger body per CDC standards, which are problematic, but are what we have. So this applies to anyone who sees their body change as part of recovery.

Kimberley:

And that was a big piece of that first step for me, which was really understanding the role that fat phobia had in my life, that it was everywhere. I had to undo layer upon layer upon layer of fat phobia to even get to a place where I would consider exposure experiments with anything that was, but again, it was fun. It was a great, I loved those conversations, but it did challenge everything that I believe to be true in the world as it is.

Giulia:

Yeah, absolutely. And I think this brings up why it can be helpful in doing any exposure work, not to rely on habitation, meaning I don’t feel distress anymore. This may just be super hard and really distressing, and it might be the best thing for you and get you towards health and a full life and everything you want. And this may feel bad for a while and it may continue to be challenging. There’s no way around that. And can we observe those thoughts from a bit of a distance and see them for what they are? Can we feel the feelings? And then this is where act really brings in the values work, which I find is so helpful when we’re talking about eating disorder recovery, what is meaningful to you? What will get you through this really, really tough experience?

Kimberley:

And that is so beautiful. That is a treatment that can beautifully be used with both conditions. Because I know for myself it was the exposure started the day that I wanted to get better, more than I wanted to stay in this situation. I had to get clear on, this isn’t working. I had prefer to be in a different body than to sit and suffer in this messy circle that I’m stuck in.

Giulia:

Yeah, yeah, totally. Yeah, it’s so true. I think that shift from in the treatment process, from sort of fake it till you make it to identifying, okay, there’s something for me that I really want this for now is such an important shift to make and is what’s really going to see the process through.

Kimberley:

Yeah. So just for the clinicians, what challenges do clinicians usually face when diagnosing or differentiating between OCD and eating disorders?

Giulia:

I think there’s a few. One, it’s hard, I think when there’s an eating disorder at play. I am curious your thoughts about this. I come from a primarily eating disorder background. I think when there’s an eating disorder at play, there’s sort of this fear of I need to get the eating disorder under control and putting that first and other diagnoses, whether it’s OCD or PTSD, get lost in the shuffle even though they’re really the logs on the fire that are keeping the eating disorder alive. So I think giving yourself the time to do a really thorough assessment of history, thoughts, behaviors, doing for clinicians, a Y box. I think it’s great to do with everybody with an eating disorder because the prevalence rates are so high. That’s A OCD measure. Just get a sense of are there any other obsessions or compulsions. And then I think really looking at, again, the functionality of the behaviors as they relate to the obsessions that they’re trying to regulate or appease. What is the biggest fear about what might happen if you don’t engage in this behavior or mental act? Is it that you will gain weight or lose control of your body? Or is it something that might be sort of outside of the domain of an eating disorder? And if it is, then that really opens up the world of different exposures that you can do and you can give your clients a bit of. You can, as we talked about, sort of threat in and out of food exposures and OCDB exposures.

Kimberley:

Yeah, and I would love everything you said. The only thing I would add is just the logistics of treatment. The biggest challenge I’ve had is there’s just not enough time in 50 minutes to address and have the person be feeling seen and heard for all that they’re suffering with in a 50 minute slot, which has been why at our center we have either increased frequency of sessions, so maybe two sessions a week or had another clinician come on the team and sort of separate the work while we’re both working together, we’re creating a collaborative team to sort of, because again, just based on the time, there’s so much to get done in 50 minutes. So that would be another sort of thing that I think a challenge that we get. And it’s hard because what is reasonable, that’s very expensive. That takes a lot of people’s time. They require people who have skills in both areas. And so if that’s not possible, we may even just have them have a dietician on the side where someone’s doing their check-in, someone’s checking their vitals to make sure medically they’re a good fit for outpatient instead of requiring more intensive treatment.

Giulia:

Yeah, I think that makes a lot of sense. With eating disorders in particular, I think working as part of a team is so helpful so that ideally the therapist doesn’t have to hold a ton of the food police stuff. What did you eat this week? How many times did you purge? I really love it if I don’t have to monitor in that way, and I don’t want to put that all on the dietician, but if we can share the responsibilities a bit, I think that can be really helpful. I remember at one point hearing an outpatient clinician talking about a case and saying, we’re doing one PTSD session and one eating disorder session or something like that. And I understand that, especially if you’re using a specific intervention for PTSD, but I think also to take the pressure off of yourself a bit and we can focus on the thoughts and the behaviors, whether it’s contamination or fear of weight gain, it’s thoughts and behaviors

Kimberley:

For sure. I think that when you address it all at once, the big pro of that is it does reduce the whack-a-mole, like playing out of it because there’s one focus and one way to deal with it, and it’s pretty cohesive across. But it does get confusing when you’re like, well, do I do this? Do I do that? What should I do for which? So I think that’s a really appropriate way to address it.

Giulia:

Yeah. One point just on that, when I was training, this was 10, 15 years ago now for eating disorders, it really was this sort of sequential model of get the eating disorder under control and then you can tackle the trauma or OCD or anything else. But if you don’t get the eating disorder stabilized, anything else you address, well then it’ll exacerbate the eating disorder. And now what we know, particularly, I know I’m talking about trauma a lot, but what we know in the case of PTSD is first of all, what would happen is people would never get to their PTSD, they would go home and then they’d be triggered and then they’d go back to what they know has worked for them. And I imagine the same is the case with OCD, but if you do concurrent treatment, if you do them at the same time, they both get better. And I think that’s the case with OCD where there’s so much overlap and the cognitive style and the types of behaviors and what’s driving them rigidity control. If we can get them both at the same time, we can find remission in both.

Kimberley:

Yeah, absolutely. Absolutely. So before we finish up, I have one question that you could tie in the deep direction, but what myths or misconceptions exist around OCD and eating disorders that might hinder treatment? What might be getting in the way of people getting good care?

Giulia:

I think there’s a ton. We could probably spend a whole episode on this, right? Certainly, I’ll start with eating disorders. I think there’s a ton of prevailing myths around what an eating disorder looks like. Most people in general society, including clinicians, we don’t get a ton of eating disorder training. I think many people are still stuck in sort of like the lifetime movie white cisgender female college student diet gone wrong. And it’s really about the food and weight loss. While that can be a big component, these are very complex illnesses and have deep roots, and often those roots are tied to another mental health struggle, whether it is obsessive thinking or high levels of anxiety, rigidity, perfectionism, trauma. So really getting at the roots of the disorder I think is still a struggle for many individuals seeking treatment too, just based, as I said, on body size.

Most people in their mind’s eye think of someone who’s underweight when they imagine an eating disorder. And we know that’s less than 6% of people who struggle with these illnesses. And someone is much more likely to binge and be in a normal or larger body, again based on CD, C standards as opposed to someone who is underweight. So there’s a lot of people who are struggling with an eating disorder. It’s estimated to be about 10% of the baseline population, but only 27% of those who are struggling are going to get the treatment they need. So there’s a lot there what an eating disorder looks like and that it’s not all about the food. I think that in terms of OCD, and I’m curious your thoughts about this as someone who specializes more in this area, that OCD and OCPD are conflated. So people think of OCD and they think it’s perfectionism, it’s helpful, you’re control freak, and these are very, very distressing experiences.

They’re can be torturous. And so not sort of seeing how painful and distressing and destabilizing these cognitions can be, I still think is a real challenge or a barrier for people getting the care that they need. And over time, I’ve known people with OCD who’ve gotten radically misdiagnosed, including bipolar. It’s been confused as a delusion or anxiety or autism spectrum disorder. I’ve, over the years known many people with anorexia nvo and their OCD has gone completely under the radar because again, it’s believed to be all about the food. So I think we need to get better. It’s really assessing the obsessive thoughts and compulsions. Also, I think, sorry to keep going, but the fact that not all compulsions are external behaviors can be mental acts, that still is a barrier for people being assessed. I think our general public, but also clinicians who aren’t as well informed are still looking for the checking of the locks or the hand washing. And it’s not always that way.

Kimberley:

No. And I think it’s a language thing too. Often people with OCD never tell anybody about, they’re too afraid to tell anyone about their intrusive religious obsessions or sexual obsessions or harm obsessions or pedophilia. Yes. And so they’re not able to say the fear and before they know what they’re being put in an eating disorder clinic with no one who’s been treated for OCD, so many people we hear from in my practice have come from an eating disorder clinic, and then they’re there for a few weeks and then the clinic is saying, something’s not here. And I think that’s the importance of that assessment because if the assessment, the Y box, this assessment for CD is put in front of them, they’re more likely to be like, oh, it’s right here. I can say it because they’ve given a paper with it, which I think is helpful.

Giulia:

Yes. Yeah. I would say for any clinician listening, like a Y box, a trauma assessment, so the life events checklist, and then also asking what is your relationship with your body and what is your relationship with food?

Kimberley:

And

Giulia:

Just give them an opening because similarly, people with eating disorders won’t share. They think it’s normal. They think it’s typical. They’re not doing things that are that different than the people they see around them.

Kimberley:

And that’s true too, I think is people, a lot of my clients with anorexia don’t actually know what a healthy sized meal looks like. So for them eating maybe half of what I would eat now, to them, they actually have come to believe that that’s too much, too much food. And so it’s a lot of education around and the actual amount of food that you need to consume to keep your organs going and so forth. And that’s a full education that they weren’t expecting to get.

Giulia:

Yes, totally. The other thing we didn’t talk about is interoceptive exposures. So really exposing yourself to the physical experience of different levels of fullness and noticing what comes up. And hunger too. For one person, feeling hungry might be a sign of success. That means I haven’t eaten, I’m doing the right thing for someone else. It might feel out control. It might mean if I eat, I’m going to binge because I’m amm too out of control right now. Fullness can bring up disgust. They are all sort of tied to different things

Kimberley:

For sure. Yeah. Okay. So one last, I said the last question, but I’m just going to keep adding that into as we go. But the main thing I sort of want us to finish here in, if someone has, of course, eating disorder or an OCD, but even if they have a coexisting condition where they’ve got both, what is your experience? Can people recover from having these coexisting conditions? What are their outcomes looking like?

Giulia:

Yes. I want to say yes, full recovery is possible and you should not settle until you achieve full recovery. You deserve it, and it’s attainable. So don’t cut yourself short. And what I mean by that, particularly in terms of an eating disorder, is sort of getting to a place where you can sustain a healthy weight or you can sort of get by, but you are still tortured by food obsessions rules, rigidity tracking, right? No, not acceptable. Keep going. Tell your therapist or find a new therapist, bug them, nag them. It is absolutely possible to have a place of ease in your mind, in your relationship with food in your body. And that doesn’t mean that these thoughts don’t come up, but they have much less power. They can be fleeting. You can see them for what they are. They’re not distressing or bothersome,

Kimberley:

For sure. Yeah, I agree. I 100% agree. And I think that people need that hope because I think as soon as you do have that coexisting, you kind of feel like you’re doomed. You know what I mean? How am I ever going to navigate getting out of this mess that I feel like I’m in? But it is absolutely possible.

Giulia:

Yes. Yeah, keep up the exposures. I mean, I really think doing ERP makes you a superhero to be able to see, and I think it’s important to celebrate and look back with pride of what you’ve come through to see the distress you’ve held, the challenges you’ve moved through that you wouldn’t have imagined you could have done when you started, and to keep it up and to go back to the model if you find yourself sort of noticing an increase in symptoms.

Kimberley:

For sure. Yeah. Thank you so much. Can you tell us where people can hear about you, your practice, any social media that you have?

Giulia:

Yeah, so my name is Julius Soro. I have a website that’s julius soro.com. And my name is spelled with A-G-G-I-U-L-I-A. And you can also find me on Instagram at Julius soro PhD.

Kimberley:

Amazing. Amazing. And I will also, in the show notes, have a link to previous episodes that you’ve been on here with us. And I’m really grateful. Again, my goal is to be speaking a little more about this because I think it’s more prevalent than we think, as you’ve said. And so I’m so grateful for your time and knowledge here today.

Giulia:

Thank you for having me. This was a great conversation.

Kimberley:

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