Podcast Transcript

Episode 46: What If You Have Both? Treating OCD & Eating Disorders with Melanie Smith, PhD, LMHC, CEDS-C

[Bouncy theme music plays.]

Sam: Hey, I’m Sam.

Ashley: Hi, I’m Ashley. And you’re listening to All Bodies. All Foods. presented by the Renfrew Center for Eating Disorders. We want to create a space for all bodies to come together authentically and purposefully to discuss various areas that impact us on a cultural and relational level.

Sam: We believe that all bodies and all foods are welcome. We would love for you to join us on this journey. Let’s learn together.

Sam: Welcome back to another episode of All Bodies. All Foods. I’m Sam, your host today, and I’m here with Ashley and our wonderful guest, Melanie Smith. Eating disorders rarely travel alone. And as mental health providers, we know that effective treatment targets not only the eating disorder, but also the co-occurring medical and psychological issues. People in recovery are not only doing the hard work to address the symptoms of their eating disorders. Keep in mind, they’re also working on coping and managing the symptoms of various other psychiatric disorders, making treatment and recovery more complicated and challenging. Obsessive compulsive disorder, also known as OCD, is one of those disorders frequently diagnosed alongside an eating disorder. For example, genome-wide association studies found a link between anorexia risk and OCD risk. It’s estimated that up to 18% of people with eating disorders also have a diagnosis of OCD. So why do these disorders tend to exist together? And how do you treat both at the same time? Well, we invited Dr. Melanie Smith to help answer those questions. Hundreds of mental health professionals recently attended her training titled, Maybe It’s Both: Treating Co-occurring Eating Disorders and Obsessive-Compulsive Disorder. We knew we had to invite her on the show to learn more. Melanie Smith, PhD, Licensed Mental Health Counselor and Certified Eating Disorder Specialist is the Director of Training for the Renfrew Center. In this role, she’s responsible for developing and implementing clinical training and programming that is consistent with emerging research and evidence-based practice. Dr. Smith is co-author of the peer-reviewed treatment manual and patient workbook, The Renfrew Unified Treatment Model for Eating Disorders and Comorbidity, published by Oxford University Press. Dr. Smith is a certified eating disorder specialist and approved consultant and is a certified therapist and trainer of the unified protocol for the transdiagnostic treatment of emotional disorders. Welcome to the show, or welcome back to the show.

Melanie: It’s good to be back.

Sam: Yay, we’re excited for this topic. Your training, maybe it’s both, was very well attended. And I think there’s a lot of interest in the community, it seems like there is, how to treat both an eating disorder and OCD together. Do you get that sense?

Melanie: Yeah, I mean, it really doesn’t surprise me too, too much. And I don’t think it would probably surprise too many clinicians that have been doing this work, that are, you know, really working with the eating disorder population. You cannot ignore the similarities and the overlaps in symptom presentation. And the more that you dig into it, the more that you learn about it, the more you’re, especially if you’re really kind of diving into the literature, the more that you see really core shared mechanisms that drive both eating disorder symptoms as well as OCD symptoms. So, the more that we kind of see those things, I think the harder it is to ignore that. And the more important it is that we spend time really thinking about these big picture questions of not only what are these factors that are contributing to the development of both of these really significant conditions that really do have a significant impact on functional, like people’s quality of life and functioning. So yeah, I think it’s kind of a pretty good time for us to keep digging into this a little bit more than maybe what we had in the past.

Sam: Yeah, I thought we could start at the basics. What is OCD? What are the signs? What should we be looking out for? There might be loved ones listening. Maybe they’re thinking, oh my gosh, is my child struggling with OCD? What am I seeing here? Can you kind of enlighten us?

Melanie: Yeah, I will do my best. And the reason why I’ll say I’ll do my best is that something that’s important to know about OCD is it does not look the same in everyone. And I think that is often a way that it gets missed. And a lot of people go misdiagnosed or undiagnosed with OCD often for a pretty long time. Even people that are like in mental health treatment of some form before it’s actually recognized that what we’re really looking at is more of an OCD like process versus maybe other processes that we might be looking at. So the definitions are like the best places that we can look at to say, okay, what is OCD would come from the DSM, right? And also from the ICD, the International Classification of Diseases. Where they overlap is basically that we’re saying that there’s the presence of both obsessions or obsessional thoughts and compulsions or both. And the or both is actually important because a lot of times where it gets missed is that folks are looking for both obsessions and compulsions to happen in a chain sequence. And that may not actually be the way that it looks like for everyone. So an obsession or obsessional thought would be like a recurrent persistent. A lot of times people use the word intrusive thought or image or urge that is often pretty distressing, pretty unwanted. You don’t want to be having this thought popping up and recurring in your head. And there’s a strong then desire to make that thought, image, or urge go away because it’s so distressing, because it’s so upsetting. And that’s actually what sets us up for then the compulsion or the compulsive response. So the compulsion would be any sort of repetitive behavior or a mental act, and I want to talk about that more, so we’re putting an asterisk on that, that you feel driven to perform to make that obsession or thought, that upsetting, distressing, yucky thought go away. You try to neutralize it. So that’s the compulsion. Whereas, a lot of times we think about compulsions as behavioral manifestations that we can see, like checking rituals, decontamination rituals, things like that but a lot of compulsions are actually unseen and are mental. These are like mental acts that people do. So a lot of times where the diagnosis or the identification gets missed is because we might be looking for these like overt behavioral, repetitive behaviors that we might see like on a movie that portrays OCD, but that may not be the way a lot of people experience it actually. And it may just be actually much more an internal compulsion to repeat a prayer or a mantra or to think and overthink and overanalyze the situation over and over and over again and become really like twisted up in that, that could be the compulsion rather than someone tapping, touching, checking, cleaning, things like that. So that’s a key way that it kind of gets missed. So again, obsessions, the name’s pretty straightforward though, at least, right? With obsessive-compulsive disorder. So again, the presence of obsessions and compulsions are both. The only other, I think, important things to think about when trying to determine is this OCD or is this something else? And this is true with any mental disorder is one, what is the level of functional impairment? Like how much does this get in the way of someone’s life? Because there’s other times and situations where we might have an overemphasis or uncertain ideas or thoughts or topics or things and that might just be preferences or that might be driven by other things that may not be causing distress and it may not be getting in the way of someone’s life. If that’s the case, we wouldn’t necessarily identify this as OCD. But folks with OCD do acknowledge quite a bit of functional impairment. Most people would fall into, or they would self-identify falling into a moderate or severe category of saying that this really does have an impact on my you know, my relationships, my academic experiences, my occupational experiences, how much I engage in recreational or leisure activities and how much anxiety or distress is associated with that. So I think that’s always an important thing to consider as well. Oh, and it’s also very time consuming, right? So these obsessions and compulsions, especially that like looping, obsessional intrusive thoughts takes up a lot of time and space. You know, so it’s just incidental that pops in your head and it pops right back out. It might be it might be upsetting. It might be distressing, but it may not be an OCD like process. So what I always look for or think about is the process or the mechanism, not so much like the behavioral checklist.

Ashley: Do you tend to see a lot of rigidity in folks that present with OCD? So like I have to engage in this mental act, as you were saying, or this behavioral pattern or else I feel like I might have a panic attack?

Melanie: Yes, very explicitly so. And I think that that’s one of those, when we start talking more about it, again, about mechanisms or another way to think about that is like drivers or like reasons that someone might develop this pattern. Some of the core mechanisms that are really at play here with OCD is this intolerance for uncertainty, right? Like I’m very uncomfortable with not knowing what’s going to happen or not knowing how I’m going to feel and I can’t tolerate that feeling. So there are these compulsions or safety behaviors is another way that you might, that I engage in to try to make myself feel better or less uncertain because that is not tolerable to me. So a lot of intolerance and uncertainty, a lot of harm avoidance, right? I don’t want to feel this discomfort or any sort of potential bad outcome because I’m often going to assume that there’s going to be some sort of bad or catastrophic outcome. and I’m trying to prevent or protect myself from that, which then people intuitively and somewhat adaptively, but not always adaptively, identify strategies for keeping themselves safe. And a lot of times that safe is actually more like emotionally safe feeling, meaning not uncomfortable, not in that icky place of uncertainty. So that’s where that rigidity kicks in because they often will develop long list of rules about what they will do, what they won’t do, what types of experiences they’re willing to have in order to prevent themselves from feeling that uncertainty that they find so intolerable. So yes, rigidity is a pretty marked observable characteristic in many cases, not always, but certainly a lot. But it’s a self-protective rigidity, right? It’s preventing myself from feeling unsafe and uncomfortable.

Sam: Right, there’s that relief that immediate emotional payoff where it’s like, oh, this compulsion made me feel a little bit better temporarily. And that can be really reinforcing.

Melanie: Super reinforcing, more reinforcing than getting a reward for doing the hard thing.

Sam: Yeah.

Melanie: And this is how it keeps going. And this is how really a lot of, emotional disorders kind of take hold within someone and grow over time is because it is so self-reinforcing in this way, because none of us want to feel discomfort or distress. Like we are hardwired to not want to feel that way. Some of us have more capacity in our ability to tolerate that in others, which is actually a key thing to think about when thinking about how do we treat it, is how do we build that capacity for folks to tolerate that uncertainty if we know that the intolerance of uncertainty is a core driver of this in the first place.

Sam: Right. That makes sense. I have a quick question. What’s your perspective on OCD getting misdiagnosed? Is it sometimes thought to be something else?

Melanie: Yeah, a lot of times. A lot of times, one of the most common things that it might get misdiagnosed at is just more like generalized anxiety because often folks with OCD do just kind of overtly present as just anxious in lots of different ways. But again, if you’re not really from a clinician perspective and assessment perspective, kind of digging into the driving mechanism that’s keeping it going, you can you can kind of miss it. Now, sometimes that’s not the end of the world, depending on the types of treatments that you use, because if you’re using treatments that are targeting those core mechanisms, whether you call it generalized anxiety or whether you’re more specific with OCD or whether you’re, you know it may not matter that much if you’re using a treatment that is designed to be helpful in both areas. And it’s also not uncommon for folks with OCD to also have generalized anxiety. And actually, if you look at the DSM and you look at all of the rule-outs, I think that gives you, it’s a very long list, and I actually have them pulled up because I wouldn’t be able to remember them all, but I had a feeling you might ask something like this. So GAD being the first, generalized anxiety disorder being the first, but body dysmorphic disorder, which is actually in the same chapter or category in the DSM. It’s actually not under eating disorders. It’s not under anxiety disorders. It’s under obsessive compulsive and related disorders because there are so many shared aspects, but it’s also super specific to body, right? To bodily, you know, to, you know, obsessions and compulsions specifically around the appearance, shape, size, whatever of body but also a lot of similarities, but still not the same as hoarding, trichotillomania, excoriation or skin picking, like hypochondriasis or now called illness anxiety disorder. While there are still notable elements, especially with compulsive behaviors that are difficult to change of impulse control issues, it’s not necessarily an impulse control disorder, even though there is an impulse control struggle with when acting on compulsions. And a really important rule out though, is that folks need to recognize that whatever the obsessional thought is and the compulsion that follows it is something that is coming from their own internal, like mind body experience, it’s not coming externally meaning, right? So it’s definitely not the same as, and a big key rule out would be like any sort of psychotic process or thought disorder process. Meaning these intrusive thoughts are not being intruded into my brain by the government through radio waves or anything like that, right? Like that would be a rule out. That’s not OCD. That would be more of a thought disorder type process. So there’s lots of diagnostic questions to ask to kind of get down to it as to whether or not this is or isn’t OCD. And again, sometimes I think that’s a useful diagnostic process to dig into. Sometimes depending on the type of treatment you use, maybe it may not be that critically important to determine the difference. But we’ll probably get to that later.

Sam: Yeah.

Ashley: Thanks, Melanie. That was great information initially. Okay, so a question about, I kind of want to talk about like social media for a second or just mental illness represented in the media. We know that it can come in many forms and we know that like, you know, on TikTok and the other social media people love to diagnose other people and say things like, you’re so OCD if, etc. So can you help us kind of bust some of the myths that we’ve been hearing in the media, in social media? What are the stereotypes that we hear? What is actually correct about OCD?

Melanie: Yeah. That’s a great question and probably one of the most important ones. And when I’m doing a training, it’s usually where I start, as I start with the myths first, because most of us, even clinicians who have some training, if it’s not like targeted specific OCD training, probably subscribe to some of these same myths. So you know, media representations of OCD, whether it’s social media, television, movies going way back, do tend to only illustrate one specific kind of stereotypical archetype of OCD, which often is someone who is, as you mentioned earlier, highly rigid, which we’re not saying that rigidity isn’t a part of it, but it isn’t always. And it’s not the only or most prominent component. A lot of times what you see illustrated in the media are high levels of perfectionism, orderliness, cleanliness, concerns about germs or tidiness or you know, I need to sit in this spot and I can’t sit in that spot because that’s my spot, things like that, which all of those are things that absolutely can be part of someone’s experience with OCD But it is not in any way all-inclusive and really does miss actually a vast majority of the OCD subtypes. So I mentioned there were a lot of rule outs there’s also a lot of like subtypes and when we say subtypes really what we’re talking about is like descriptions of the way that OCD can look or manifest. Right? So, the most common one that we see, subtype that we see illustrated in media is contamination. Contamination OCD, which again, is fear of like icky, sticky, dirty, yucky things, germs, viruses, bacteria, you name it, right? And that while that is a common OCD stereotype, there are people with OCD who have very messy rooms, who are not very orderly and tidy, may not be particularly perfectionistic, but there are certain subtypes that absolutely do fall with that. So I just, I think the real issue is not that that’s not how OCD looks, but that’s how OCD looks for a certain subset of the people that have it, but it really leaves out everybody else in their various presentations, which I do think absolutely leads to part of that under diagnosis or misdiagnosis part is that we’re as clinicians, we’re looking for those very specific things, which is only illustrative of a few or smaller number of folks than really the broad. It’s a very, there’s a ton of variance in the way that this can look behaviorally. And I just, I think without like some extra training and work on your part as a clinician, it’s just very easy to miss all of that stuff.

Ashley: Speaking of those subtypes, can it present differently, not that this is a subtype, but do we see it differently in males versus females? Or is it really… inaudible.

Melanie: I do think I’d have to look back more. I don’t have this like this level of detail like memorize but in my presentation, I have some slides on it. But there are some gender differences in men and women as far as like rates of even like who has OCD, there are some gender differences, but both men and, you know, or any, any person across the gender spectrum can develop OCD. Any person of any ethnic or racial background can develop OCD. Anyone at any age, very, very young ages can start demonstrating OCD-like characteristics. So that’s, you know, just something also to point out is that we have a lot of variability in the symptoms, but we just have a variability in the type of people, which is basically all people could develop an OCD-like pattern. Going back to subtypes a little bit, I do want to say something else about subtypes is that there are certain subtypes that really freak people out a lot. And by people, I mean, not only the people that suffer with it, but clinicians. And often this is where OCD gets missed or misdiagnosed as something different. So one of the subtypes, you know, well, there’s different language around subtypes and categories also. There’s not a lot of universal language here, but I’m going to lump them together as like really aversive obsessions or compulsions. So obsessional thoughts or compulsions around sexual behaviors, paraphilia around gender or sexual identity, around violence or harm. These are things that make most people uncomfortable, even probably as some of our listeners might be listening to this and saying, oh yeah, I don’t want to work with that, or oh, that sounds scary. And that I think it’s really important to highlight that there is no worse type of OCD to have, right? So even though there might be some that are less represented in the media and we as clinicians are more uncomfortable working with, because the content of the obsession or the compulsion makes us uncomfortable because these are things that are not like socially appropriate or, you know, can be, again, we can experience our own fear or uncertainty around them actually is not tied at all to the way that we should treat folks. And it’s not tied at all into what their potential outcome could be. So there is no more like worse. So for example, I’ve supervised a lot of clinicians, right? And I’ve heard a lot of clinicians say like, I’m comfortable with working with people with more stereotypical OCD, contamination, fears and worries, probably, you know, high rates of perfectionism, rigidity. Like I feel comfortable doing that but if someone’s obsessions and compulsions are around intrusive thoughts that they might be a pedophile or that they want to stab their partner, that makes me uncomfortable and I’m not willing to do that. Mostly because I think we misunderstand the process of what’s happening in the obsession and the compulsion. And we overestimate the risk of the threat, which actually is something that the person struggling with OCD does as well. They overestimate that just because I have this thought, this intrusive thought, that I really wish on a star, I would never into my brain, but guess what it did, it does not mean that they are actually any more likely to act on it. So when thinking about harm, OCD, violence, you know, violence, you know, related OCD, sexual or paraphilia related, those folks are no more likely to perpetrate crimes or violence or, you know, sexual violence without consent than anyone else. And I just think that’s a really important thing for clinicians and for people who are struggling to hear. It does not make people bad. It doesn’t make people bad people. It doesn’t make them not worthy of help. And it doesn’t also mean that they’re not able to be helped. Folks with OCD of all different subtypes can make significant improvements in their functioning, regardless of how aversive or scary or uncomfortable the intrusive thought or compulsion is. So I think like, if there’s anything that I want people to hear about, it’s actually that. Because I think that’s a big piece of how and why people don’t get the quality care and help that they need because of that profound misunderstanding.

Sam: This is so important because I’m just thinking to myself how much courage it would take for certain clients to admit that I have these thoughts and how much shame can be associated with them and fear that this fear that they’re going to act out on them. And then to have a clinician who maybe is also afraid that they’re going to act out on it can really do a lot of harm.

Melanie: Absolutely. If someone is feeling judged in that way, one, it just reinforces their beliefs and their overestimation of that risk and that threat for themselves. And yeah, it’s not going to likely result in the trust and therapeutic alliance that needs to happen in order to actually facilitate change and do good quality evidence-based treatment around OCD. So this is a huge issue that really, again, I think is a big contributor to folks and staying, struggling a lot longer than maybe they need to.

Sam: And struggling in silence.

Melanie: Yeah, without support and without feeling, again, like it’s safe enough in that therapeutic relationship to be very honest, which is what is necessary to be that, to be honest, to be transparent, to be vulnerable. When you take that leap and that risk of being vulnerable and saying the big scary thing out loud and you’re met with judgment or uneasiness on the part of the clinician, like I can’t think of something that kind of interrupts or ruptures that alliance more than that.

Sam: Absolutely. Just to bring things back to OCD and eating disorders for a moment, I’m familiar with some of the research, those genome-wide association studies that found anorexia nervosa risk seems to travel alongside OCD risk as well. So there seems to be a genetic explanation for this, but from your perspective, why do you think OCD and eating disorders seem to travel together so frequently?

Melanie: Yeah, well, and I think starting with that genetic place, I think is important because there are, just as I mentioned earlier, there are shared mechanisms, right? That intolerance of uncertainty, we absolutely see that in eating disorders. Harm avoidance, we certainly see that in eating disorders, anxiety sensitivity, which is the anxiety about anxiety that folks feel, meaning that once I start to feel anxiety and I notice it in my body and my body starts to react, I then get more anxious and freak out even more. So folks with all of those same characteristics, which really are traits, which traits are tied to our genetics and our temper, our temperament. Right. Those are shared traits. And we know that some of those traits do have genetic origins. So there is actually very similar rates of heritability of eating disorders as there are of OCD. And like you said, there are shared overlapping genetic risks with OCD, with eating disorders, and actually also with autism and even Tourette’s syndrome, that all of these have some shared gene explanations. Now, there for all of these conditions that I just mentioned, there is no one single gene explanation, right? So unlike other conditions, like one of the best examples I can give, cause a lot of people know about it or understand it is like for risk development, for developing breast cancer, right? Like they’ve identified the BRCA gene, right? They can pull that out and say, this really increases your risk of developing breast cancer. They don’t have that. We don’t have like an eating disorder gene or an OCD gene that we can but there are clusters of genes that do seem to kind of hang together in these share that have these same shared temperamental, temperament styles and character traits that are shared and overlapping. So for both eating disorders and OCD, genetics absolutely do increase folks’ vulnerability and risk. Now, what we also then have to add, right, is that environment and many other factors very much interact with that, right? That’s how and why we study epigenetics is looking at all those environmental factors, stressors, access to resources, behavioral responses to our existing temperamental traits. All of those things interact with that to then determine ultimately whether someone does or doesn’t develop it.

Sam: Yes, our DNA is not our destiny.

Melanie: It’s not our destiny. But it’s useful to understand it, right, and understand what our vulnerabilities are, so that maybe we can work to protect against that or prevent that, right? But yeah, it’s not our destiny and we also can’t change them. We can’t unring the bell.

Sam: Right, right. Well, and there’s even theories that we inherit, we might inherit also genetic things that protect us from mental health. So on one side of the coin, we can’t change our vulnerability that, or our risk that we inherit, but we might also inherit things that help us cope.

Ashley: Right.

Melanie: Yeah. Well, and I think another thing to point out or think about with that interaction effect of our kind of genetic predisposition, but then there are these, you know, quote unquote environmental factors that can influence that direction. Thinking about, you know, a kid that is born with high trait anxiety, high levels of all of those kinds of things that I mentioned earlier, anxiety sensitivity, intolerance of uncertainty, harm of avoidance, right? It’s like a recipe to develop an eating disorder or OCD or some other kind of related over-adopting condition, right? But when we think about the context of parenting and bringing up this young child with these vulnerabilities, that to me is an environmental factor we can make some change in, right? Because if we identify that our child has these tendencies, how we react might reinforce those tendencies, right? We over-accommodate, we say oh no sweet baby, angel, you cannot ever be anxious or uncomfortable or uncertain and I will try to craft your world in your environment so that you never have to experience this uncomfortable uncertainty about what’s going to happen. Or you never have to experience difficult situations or anxiety or higher expectations because that’s too much for you. That sort of over accommodation can, in combination with that genetic predisposition, really allow those traits to be, you know, really expressed in a pretty significant way. And it’s just kind of becomes part of that family system. Whereas if you have a parent that kind of understands this vulnerability and also understands the way that this vulnerability could limit their child, right, over time. And we’re not just talking about children, but just for the example. And is saying, yes, you have anxiety and it makes sense that you have anxiety. It makes sense that this is uncomfortable because it’s new or unfamiliar for you and you prefer to know what’s happening. But in real life, we don’t always know what’s happening. Maybe let’s try it out. Let’s experiment. Let’s allow ourselves to be a little anxious, a little uncomfortable. It’s not the worst thing in the world. It’ll pass. It’s not dangerous. It’s not unsafe. So that’s to me is one of those big like environmental, you know, factors that we can actually do something about if we identify it and have recognition of it pretty early.

Sam: So in other words, when there’s a parent or a caregiver with their own ability to tolerate discomfort, it’s a protective factor for their kids.

Melanie: Hugely. So and again, I would say that whole explanation I just have is equally true for eating disorders as it is for OCD.

Ashley: Right.

Sam: And really all mental health disorders.

Melanie: Yeah, truly, truly. Like that’s a I mean, what I’m giving you there, right, is a is a pretty straightforward trans diagnostic conceptualization a little bit, right? But bringing together the genetic vulnerability and the kind of environmental milieu that we’re living in and how supportive or not is that of that genetic kind of predisposition.

Ashley: Right. So Mel, thinking about recovery, thinking about specifically eating disorder recovery, it can be really challenging, right? It can be hard enough. Then if somebody is also experiencing OCD alongside of that, that’s like, you know, two big things they’re working on at the same time. What are some unique factors that they may be experiencing in their recovery journey, having both an eating disorder and OCD?

Melanie: Well, you know, I’m trying to identify unique factors, but I guess maybe what I’m getting at is that maybe it’s not that unique. Because as we talked about earlier, those overlapping or shared mechanisms, that’s I think why that we see so much clinical overlap because the same mechanisms that drive OCD and the repetitive nature of it drive the repetitive nature of symptom use. Well, a first eating disorder cognitions, and then symptom use in eating disorders. So I really do always come from a trans diagnostic conceptualization where I’m really looking at the shared factors versus the differences now, which is why, you know, kind of the thesis of my presentation before that you mentioned, Sam, the maybe it’s both is like, maybe it doesn’t matter that much if we label it OCD or if we label it as eating disorders because an eating disorder because if it has same shared underlying mechanisms and the behavioral presentation is all tied up, meaning their intrusive thoughts and compulsions are related to food, eating, weight, shape and size. We are dealing with all the same thing, basically. It doesn’t really matter if we’re labeling it one or the other, but what we also see sometimes though, right, is that someone may have all of those overlapping features and, you know, but they might also have a subtype of OCD that isn’t directly related to their eating disorder, even though there’s still some shared mechanisms, right? So they may also have, I’m not going to use, I always jump to contamination. I’m not going to use contamination because that can easily tie into the food eating stuff as well. But some other, you know, subtype of OCD and identity related OCD where someone doesn’t trust that they really trust their own sense of self and like, who am I? Am I, am I, uh, gay or straight? Am I, uh, where do I exist along the gender spectrum? Where, you know, those sorts of, um, identity questions. I think there’s more and different work to do with that than maybe when we have the much more obvious overlap where the intrusive thoughts are very directly tied to the eating disorder. Now we’re still intervention-wise looking at the core mechanisms that drive that uncertainty about identity. And we’re still trying to use strategies that address that intolerance of uncertainty. But the types of things we might do in exposure work or the types of therapy homework that someone might do might be much more explicit to the type of intrusive thought that they have. But going back to an earlier point where I said, no one type of OCD is like worse than the others. And that’s important to think of as a clinician. Another important thing to think of as a clinician is that the content of the OCD of the obsessional thought is not actually what you’re treating. Like I’m not trying to convince someone what their identity is or isn’t. I’m trying to help someone tolerate their uncertainty around knowing whether they can trust their own interpretation of their identity. You know again, so it does actually come back to the mechanism place even if symptom wise the symptoms look different or like a more stereotypical OCD presentation where someone might have a lot of checking behaviors, right? Like checking if the door is locked, checking if I turn the stove off, checking, checking, checking, right? Like, yeah, you might design some behavioral interventions, i.e. exposures that explicitly practice them basically not engaging in the compulsion, which is the repetitive checking behavior, which doesn’t have an obvious overlap in that exposure with an eating disorder symptom. But at a mechanism level and at a big picture level, it does still have overlap because if I can, in exposure get you to tolerate your discomfort and uncertainty about whether you turned the stove off after checking it once, not 30 times, I would want that and as a therapist, I’d be trying to make that bridge for folks that we want to generalize that learning of tolerating that distress and that uncertainty to any distress or uncertainty you had around the food that you put in your body, what it’s going to do to your body or your weight or your shape or your size or whatever. Right. So where I’m always looking to generalize and translate and see where what’s shared versus what’s different. So I think that’s another important thing, putting my supervisor hat on for clinicians that are trying to learn and trying to grow in this is, um, I don’t think you have to look at someone with co-occurring OCD and eating disorders and be like, ooh, this is extra tough. I mean, I don’t know, maybe, you know, if we’re looking at them trans diagnostically, like I don’t, I don’t think it has to be. I think there’s, there’s more shared than there is different. Yeah. Which I think is actually important to instilling self-efficacy within the clinician of like, yes, we can do this work. I can help you with these things and I can help you with these things simultaneously, It doesn’t have, you don’t need to go to an eating disorder program and then a separate OCD program. If we have a treatment that’s targeting those underlying shared mechanisms, we should be working on all of it at the same time. And I think that’s the business, that’s the good stuff. Yeah. We can do that.

Ashley: That’s really helpful because I’m just thinking about it as someone coming really from like the eating disorder side. That makes everything that you just said made so much sense to me. Like increasing distress tolerance is really going to serve both avenues. And I’m thinking about that specifically with eating disorders, like, you know, we say sometimes like, it’s not necessarily about the food, right? And what we’re saying there is it’s not necessarily about like, right, exactly what they’re putting in their mouth or why the food is there. It’s about increasing their distress tolerance to be able to put it in their mouth. Right. And so that makes sense to me about the OCD compulsions and behaviors as well. And I’m thinking specifically about one of the subtypes that you mentioned of like, you know, violence or like, I know people have done exposure interventions before where they have left, you know, maybe knives in the kitchen and stuff like that, because it’s not about that compulsion. It’s about the distress tolerance that they’re experiencing on the inside.

Melanie: Absolutely. Yeah, and I just, I think that’s such a, first of all, just more efficient way to kind of get to where you want to go. But again, the more that we can generalize the learning in the treatment, the quicker folks are going to start feeling better and start to believe and build that self-efficacy within themselves of like, I can do this. Like, yeah, I can have this scary intrusive thought, or I can that might be around harm or violence. I can also have this really upsetting, shame-filled intrusive thought about my body or what I’m putting into it and what that means about me as a person. But if really what the thing is that’s really driving me to engage in my compulsive behaviors or my eating disorder behaviors is this emotional experience and I can build tolerance to that emotion, I can tolerate that emotion in a variety of different situations and contexts, which is why I don’t need to do 400 different exposures around every different OCD intrusive thought I have or every different eating disorder ritual or thought I have because a lot of our folks with eating disorders have a lot of different symptoms, rituals, things like that. We don’t have time to do all of that with most people. That’s a luxury that most people cannot afford to be in treatment for that long. And again, people get very exhausted and fatigued with treatment if they don’t feel like it’s like tangibly helping them sooner rather than later, which I think is another significant benefit to being much more emotion focused and targeting the emotion and the intolerance of distress rather than all of these like, diffuse symptoms that we see. You could be playing that game of trying to stomp out, whack-a-mole all those symptoms forever and not really make any headway. But if we look at the shared core underlying mechanism, intolerance of uncertainty, intolerance of negative emotions, harm avoidance, things like experiential and emotional avoidance, you can much more effectively, much more quickly make big change, big and sustainable change for folks. which is why we always want to start there in our conceptualization and have our treatment follow from that.

Sam: So quick question. I’m thinking about motivation and ambivalence in eating disorder recovery, and it’s not uncommon. Maybe there’s a client who is really motivated to work on their OCD, but not so motivated, maybe they’re not ready yet, maybe to work on their eating disorder. What’s your perspective on focusing on one, but not the other or vice versa?

Melanie: Yeah, well, and again, we see people at all different entry points, right? So I do think there’s some assessment that needs to be done, again, first to kind of identify, okay, are there maybe shared core underlying mechanisms that the patient doesn’t recognize? And if I am able to illustrate that to them effectively, maybe they will be more bought into doing that work if they can see the way that it’s connected. But a real battle with both eating disorders and OCD, because it’s not that everyone with OCD is eager to do the treatment either. Like they, folks with OCD have plenty of ambivalence as well because a lot of time those compulsive behaviors, which you might label at certain times as safety behaviors, right? Can be very egocentonic, meaning I believe that this ritual, this compulsion keeps me safe, right? Cause I feel less uncertain and less scared. And when I do it, it kind of manages my emotion and my affect. So I think we have ambivalence challenges there too. But again, I know I might sound like a broken record, but it’s for a reason, is I do try to still bring it back to mechanisms. And I think if I can get them bought into that and illustrate that, that it is actually the same underlying mechanism, one will serve the other. So if you’re more willing and open, because I want to roll a key part of motivational enhancement, motivational interviewing is roll with that resistance, normalize that ambivalence. I can roll with that and say, okay, you want to focus more on OCD related stuff because that feels more like accessible and achievable to you that you feel like that’s causing more functional impairment, okay. But I’m also not going to like keep it a secret that these are the same mechanisms that you’re experiencing in your eating disorder. So, okay, let’s work on the OCD, let’s work on these mechanisms, but I am going to point out all the ways that carries over in forming your eating disorder. And hopefully, I would like to think that might actually serve as a motivator to say, okay, I actually do realize that these things are not really that different. There may be, again, additional hurdles because someone may cognitively still have a bigger hurdle of like accepting their body in a different weight, shape or size than what it is now. So they might be able to, you know, okay, I can buy into wanting to tolerate uncertainty, but I may not be able to buy in yet that I need to accept my body for what it is. Okay, you may not be bought into that yet, but let’s work on the emotional piece first. And I do believe and have seen, right, that if we work on that emotional piece first, that does a lot of help towards and then going back to some of those tightly held beliefs that folks have, because those beliefs are held so tight because the emotion is driving them and reinforcing them. But if we can make some movement on that, then we’ll probably make it still making movement on everything anyway.

Ashley: It makes me think of like the ripple effect, you know, like the emotion is in the middle. That’s the core of what is driving this. And if I can work on that, like bigger, you know, I can work on these bigger and bigger things. And I’ve seen that too, Sam, I’m sure you have to in our, in our work, um, how our clients can come in really with this kind of disconnected sense of self and not wanting to experience, you know, the whole self and what that self has, but like leave with like this very, um, well a more solid ego state and a more solid, like, I can do, you know, I can do hard things.

Sam: Confidence. Yeah, like walking out the door with confidence. Like, wow, I can do this. What else can I do? I can do a lot of things maybe I thought I couldn’t do before.

Melanie: Yeah, it all it all builds upon itself. So, again, I wouldn’t necessarily identify that as a problem. I would say, okay, then where can we start and what again? You know, because we’re trying to build that bridge to them to see how it’s actually really not that different. One of them they might see as more tolerable or more, again, it aligns more with some specific value that is reinforced by the world at large, i.e. diet culture, wellness culture, etc. But again, once we’re handling that emotion more effectively, I think some of those messages that come from elsewhere are less meaningful in that way. So it serves a multitude of purposes.

Ashley: Yeah. So Melanie, if Someone is listening to us today that might feel like, oh, some of this is landing with me, regardless of OCD or eating disorder. What would you suggest be the first step for them to receive support with this?

Melanie: I mean, I’m always, when you’re talking about steps to receive support, especially if you’re talking about like professional, you know, identifying and working with a professional, I am a stickler for specialty care. I think it’s important that you see specialists. And so, because a lot of the information and knowledge I have about eating disorders and about OCD, I did not get, not a lot of it, all of it came outside of graduate school, right? So I do think folks with specialized training and experience are really who you need to be focusing on. Because again, when we think about all those years that people go misdiagnosed and undiagnosed, a lot of times it’s because they’re working with folks that really don’t know what they’re looking at, which doesn’t mean that folks that are generalists don’t know what they’re doing, but they don’t have the experience to be able to identify it more clearly. So I would explicitly be looking for people that not only advertise themselves as being an eating disorder specialist or whatever, but actually having training and professional experiences to back that up. So yeah, you got to do your homework with that, which is not always easy. And just because something’s on a website doesn’t make it the truth, the whole truth and nothing but the truth. But I do really prioritize that. I do prioritize folks using evidence-based treatments. So when we’re talking about evidence-based treatments for eating disorders, evidence-based treatment for OCD. OCD treatment, the gold standard of treatment is some form of CBT, which there are lots of different forms of CBT plus ERP, exposure and response prevention. I personally can’t conceive of OCD treatment being effective without the ERP component. So again, individuals that specialize in using exposure type strategies, I do think that that’s really, really critically important. Otherwise you might be talking about your obsessions and compulsions and talking about them, talking about them, talking about them in typical kind of psychotherapy constructs. And you may just not really get anywhere other than just actually sometimes, you know, not doing OCD targeted treatment in this way and we think about this repetitive looping intrusive thoughts can actually make that worse because you’re actually just overthinking them, you know? So, which is why the identification is so important. So specialists first.

Sam: For our audience members out there who want to learn more about OCD Any resources you can share and then how can they connect with you and learn more from you?

Melanie: Well, a great resource for OCD information because I would imagine our audience includes a lot of folks that work in or experience eating disorders themselves, right? So they’re aware of a lot of those resources but may not or want and are wanting to learn more about OCD. The best direct and free resource is IOCDF, the International OCD Foundation. They have a wonderful website, iocdf.org. Lots of wonderful resources available free on their web page. There’s a lot more resources available, if you become a member of their professional organization, which may not necessarily be the step that most folks need to take, but for your basic like information, especially with tools for like diagnosis and identifying and differentiating OCD from other conditions, very useful and they also have good resources for patients themselves and for family members. And again, I love a free resource. As far as treatment approaches, if the stuff that I was talking about today appealed to you, I was talking directly and straight from the Renfrew Unified Treatment Model for Eating Disorders. So I’m always careful of not being a commercial for it, but I want to be a commercial for it because we worked for a really long time on it. And I really have seen it help a lot of people. The resources for that, we have resources on our Renfrew website, obviously, but the books that patients, we have a patient workbook, those are available on Amazon. And what I’ll tell you is we don’t make any money off of it. So it’s not really a sales pitch. It was truly a labor of love. So I do feel comfortable endorsing it and saying maybe you should check it out. Do we have a clinician version and a patient version. A lot of folks like to use it as a semi-version of self-help, I’m not necessarily recommending that be the way that you’re doing it, but it’s a good way to kind of learn and like get a sense of it that then can be very useful in treatment, but treatment with a professional that specializes ideally.

Ashley: Melanie, thank you so much for being here with us today. I feel like this was so incredibly helpful. And I can’t wait for our audience to hear this episode. And thank you to our listeners for being here with us as well.

Melanie: Thanks for having me again.

Ashley: Thank you for listening with us today on All Bodies. All Foods. presented by the Renfrew Center for Eating Disorders.

Sam: We’re looking forward to you joining us next time as we continue these conversations.

[Bouncy theme music plays.]