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Section 10
Obsessive-Compulsive Disorder in Individuals with Eating Disorders

Question 10 | Test | Table of Contents

Perfectionism is a central feature of eating disorders, typifies the acute phase of eating disorders (ED), and persists after recovery from ED. Obsessive- compulsive disorder (OCD) is also frequently comorbid with ED—10%–60% in anorexia nervosa (AN) and 0%–40% in bulimia nervosa. The prevalence of obsessive-compulsive personality disorder (OCPD) in ED patients is similar to that of OCD—3%–60%, with lower prevalence reported when bulimic symptoms are present (Herzog et al.,1992). Family studies report increased prevalence of OCD and OCPD in relatives of individuals with ED. OCPD occurs more frequently in relatives of individuals with OCD than in relatives of controls (Samuels et al., 2000). It is unclear whether OCD and OCPD share common causative factors or represent distinct entities. Finally, studies on the relation between perfectionism and obsessive-compulsive traits reveal a significant correlation between some perfectionism subscales and obsessive-compulsive traits.

Although perfectionism, OCPD, and OCD have all been implicated in the risk for ED, our understanding of how they interact in individuals with EDs is limited. We explored the nature of the relation among perfectionism, OCPD, and OCD to assist with the refinement of behavioral endophenotypes underlying vulnerability to ED.

Participants provided informed consent and were recruited from the Price Foundation Genetic Study of Bulimia Nervosa. Full details about the methodology and sample have been detailed elsewhere (Kaye et al., 2004). All sites received approval from local institutional review boards.

Probands (age 13–65 years) met lifetime criteria for BN, purging type, as defined in the 4th ed. of the Diagnostic and Statistical Manual of Mental Disorders (DSMIV; American Psychiatric Association, 1994). Affected relatives (age 13–65 years) were biologically related to the proband and had at least one lifetime ED diagnosis. Only relatives with some form of AN and/or BN were included in these analyses. Males were excluded due to their rarity. Total sample size for the current study was 607. Based on detailed clinical interview data, participants were subtyped as follows: AN, restricting or purging subtype (absence of lifetime binging; n = 75); AN, binging subtype, or diagnoses of both AN and BN during the course of illness (presence of both AN and BN [ANBN] features; n = 275); and normal weight BN (absence of any lifetime AN; n = 257).

Lifetime EDs were assessed with the Structured Inventory of Anorexia Nervosa and Bulimic Syndromes (SIAB; Fichter, Herpertz, Quadflieg, & Herpertz-Dahlmann, 1998), and with Module H of the Structured Clinical Interview for DSM-IV (SCID). Lifetime OCD and OCPD were assessed via the SCID-I (First, Gibbon, Spitzer, & Williams, 1997) and SCID-II (First, Gibbon, Spitzer, Williams, & Benjamin, 1997). Perfectionism was measured by the Multidimensional Perfectionism Scale (MPS; Frost et al., 1990), which includes six subscales: Concern over Mistakes (CM), Doubts about Actions (DA), Personal Standards (PS), Parental Criticism, Parental Expectations, and Organization (O). The PS subscale contains items referring to the setting of high standards and the importance placed on these standards for self-evaluation. The DA subscale refers to the tendency to doubt the ability to accomplish tasks.

The CM subscale reflects the tendency to interpret mistakes as failures. The O subscale reflects the importance placed on orderliness and Parental Expectations and Parental Criticism are measures of perceived parental attitudes and behaviors.

Statistical Analyses
Participants were stratified into Group 1, neither OCD nor OCPD; Group 2, OCD, but no OCPD; Group 3, OCPD but no OCD; and Group 4, OCD and OCPD. Mean differences on the standardized perfectionism dimensions across the four obsessive-compulsive groups were examined using analysis of variance with corrections for clustered sampling using generalized estimating equations (GEE; Diggle, Liang, & Zeger, 1994).Due to correlations between some scales and ED subtype, subtype was entered as a covariate. ED subtype _ scale interactions were not included because none was significant. Analyses were conducted using GENMOD in SAS version 8.1 (SAS, 1996). This research was reviewed and approved by an institutional review board.

The frequencies of OCD, OCPD, and OCD/OCPD in the total sample were 20%, 13%, and 16%, respectively. No significant differences in comorbidity frequencies were found among ED subtypes (w2 = 3.79, df = 3, p = .28)—15% of the AN group, 21% of the ANBN group, and 21% of the BN group had OCD, and 15% of the AN group, 12% of the ANBN group, and 12% of the BN group had OCPD. OCD/OCPD was seen in 16% of the AN group, 20% of the ANBN group, and 12% of the BN group. Finally, 54% of the AN group, 48% of the ANBN group, and 54% of the BN group reported neither OCD nor OCPD.

Table 1 Analysis of variance comparing four groups with GEE correction for each of the perfectionism measures.


F (p)

OC Group Differences

Group 1
M (SD)
(n = 310)

Group 2
M (SD)
(n = 123)

Group 3
M (SD)
(n = 76)

Group 4
M (SD)
(n = 98)

Concern over Mistakes

43.83 (.0001)

1≠2, 3, 4; 2≠4

27.21 (9.7)

30.89 (8.7)

32.98 (8.6)

35.36 (8.4)

Doubts about Actions

54.35 (.0001)

1≠2≠3, 4

10.92 (3.9)

12.51 (3.8)

14.13 (3.6)

14.69 (3.9)


5.39 (.5)


22.09 (5.9)

23.24 (5.6)

23.07 (5.2)

24.47 (5.5)

Parental Criticism

15.09 (.0002)

1, 2, 3≠4

10.31 (4.6)

11.36 (4.7)

10.53 (4.7)

12.73 (4.9)

Parental Expectations

14.19 (.0003)

1≠2, 4

13.40 (5.7)

15.03 (5.9)

14.79 (5.4)

15.80 (6.0)

Personal Standards

23.82 (.0001)

1, 2≠3, 4

24.02 (6.6)

25.01 (6.1)

27.41 (5.1)

27.95 (5.8)

Note: Groups: 1 = neither OCD nor OCPD; 2 = OCD only; 3 = OCPD only; 4 = OCD+OCPD. OC = obsessive-compulsive; OCD = obsessive-compulsive disorder; OCPD = obsessive-compulsive personality disorder; GEE = generalized estimating equations.

Across the four groupings, all perfectionism dimensions but the O subscale showed significant variability across groups (Table 1). Overall, Group 1 exhibited the lowest scores and Group 4 the highest scores on perfectionism subscales. The CM and DA subscales discriminated best between individuals with and without an obsessive-compulsive diagnosis.

However, both of these subscales were better indicators of OCPD than OCD. PS was associated with OCPD. In contrast, Parental Expectations scores were significantly higher in Groups 2 and 4, suggesting a stronger association with OCD. Parental Criticism scores were significantly higher in Group 4, possibly indicating an association with generally elevated psychopathology.

Perfectionism appears to be more closely associated with obsessive-compulsive personality features rather than OCD. The pairing of perfectionism with OCPD may be a relevant core behavioral feature underlying vulnerability to ED. Although our study is strengthened by the large, well-characterized sample size, there are also limitations. Most notably, the sample is composed of families in which more than one member had an ED. Although none has yet been detected, subtle differences may exist in personality and comorbidity in individuals from higher density families in comparison to sporadic cases. The combination of aspects of perfectionism such as concern over mistakes and doubts about actions and features of OCPD may represent an important phenotype indexing ED risk or prove valuable for refining phenotypic definitions in genetic studies of ED (Westen & Harnden-Fischer, 2001).
-Halmi, Katherine A. MD; Tozzi, Federica MD; Thornton, Laura M. PhD; Crow, Scott MD; Fichter, Manfred M. MD; Kaplan, Allan S. MD; Keel, Pamela PhD; Klump, Kelly L. PhD; Lilenfeld, Lisa R. PhD; Mitchell, James E. MD; Plotnicov, Katherine H. PhD; Pollice, Christine MPH; Rotondo, Alessandro MD; Strober, Michael PhD; Woodside, D. Blake MD; Berrettini, Wade H. MD; Kaye, Walter H. MD; Bulik, Cynthia M. PhD. International Journal of Eating Disorders, Dec2005, Vol. 38 Issue 4.

Personal Reflection Exercise #3
The preceding section contained information about the relation among perfectionism, obsessive-compulsive personality disorder and obsessive-compulsive disorder in individuals with eating disorders. Write three case study examples regarding how you might use the content of this section in your practice.

Cognitive Behavioral Therapy
for Eating Disorders: A Map
of the Systematic Review Evidence Base

Kaidesoja, M., Cooper, Z., & Fordham, B. (2023). Cognitive behavioral therapy for eating disorders: A map of the systematic review evidence base. The International journal of eating disorders, 56(2), 295–313.

Peer-Reviewed Journal Article References:
King, J. A., Korb, F. M., Vettermann, R., Ritschel, F., Egner, T., & Ehrlich, S. (2019). Cognitive overcontrol as a trait marker in anorexia nervosa? Aberrant task- and response-set switching in remitted patients. Journal of Abnormal Psychology, 128(8), 806–812.

Solomon-Krakus, S., Uliaszek, A. A., & Bagby, R. M. (2020). Evaluating the associations between personality psychopathology and heterogeneous eating disorder behaviors: A dimensional approach. Personality Disorders: Theory, Research, and Treatment, 11(4), 249–259.

Wahl, K., van den Hout, M., Heinzel, C. V., Kollárik, M., Meyer, A., Benoy, C., Berberich, G., Domschke, K., Gloster, A., Gradwohl, G., Hofecker, M., Jähne, A., Koch, S., Külz, A. K., Moggi, F., Poppe, C., Riedel, A., Rufer, M., Stierle, C., . . . Lieb, R. (2021). Rumination about obsessive symptoms and mood maintains obsessive-compulsive symptoms and depressed mood: An experimental study. Journal of Abnormal Psychology, 130(5), 435–442.

In the perfectionism, obsessive-compulsive personality disorder and obsessive-compulsive disorder study, what scores were significantly higher in Groups 2 and 4, suggesting a stronger association with OCD? To select and enter your answer go to Test

Section 11
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