Relationship between orthorexia and obsessive-compulsive symptoms in patients with generalised anxiety disorder, panic disorder and obsessive compulsive disorder

Abstract

Orthorexia nervosa (ON) refers to an intense desire to consume healthy or biologically pure food that is free of artificial products. ON is not regarded as a separate eating disorder, but its clinical presentation shares common features with obsessive- compulsive disorder (OCD) and eating disorders. The current study examined 130 patients who were diagnosed with OCD (n = 49), panic disorder (n = 44), and generalized anxiety disorder (n = 37). Padua Inventory Washington State University Revision (PI-WSUR), The Eating Attitudes Test-40 (EAT-40), and the ORTO-11 test were given to the participants. There were no significant differences between patient groups in the mean scores of eating attitudes and orthorexia symptom severity. No significant association between ORTO-11 scores and body mass index was noted. Moderate correlations (r > 0.30) were obtained between orthorexia symptom severity and obsessive- compulsive symptom severity, EAT-40 total score, and checking and dressing/ grooming compulsions. These findings suggest that ON, a pathological inclination towards an obsession with healthy eating, is not specifically associated with any of the investigated illness groups. However, it has moderate correlations with the ritualistic signs of OCD. Underlying worry may predispose people to develop a compulsion to create the pure diet.

Full text

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22
DOI: 10.5455/NYS.20151221025259
Relationship between Orthorexia and Obsessive-Compulsive
Symptoms in Patients with Generalised Anxiety Disorder,
Panic Disorder and Obsessive Compulsive Disorder
Cana Aksoy Poyraz1,
Ebru Yücel Tüfekçioğlu2,
Armağan Özdemir3,
Alper Baş4,
Ayşe Sakallı Kani4,
Ethem Erginöz5,
Alaattin Duran6
1Psychiatrist, 4Resident, 6Professor,
Istanbul University Cerrahpaşa
Medical School, Department of
Psychiatry, Istanbul
2Resident, 5Professor, Istanbul Uni-
versity Cerrahpaşa Medical School,
Department of Public Health, Istan-
bul,
3Psychiatrist, Bakırköy Mental
Health and Neurological Diseases
Training and Research Hospital,
Istanbul
Corresponding Author: Cana Aksoy
Poyraz, Psychiatrist, Istanbul Uni-
versity Cerrahpaşa Medical School,
Department of Psychiatry, Istanbul.
Phone: +90 532 715 95 04
E-mail: canaaksoy@yahoo.com
Date of Receipt: 04 June 2015
Date of Acceptance: 13 December
2015
ABSTRACT
Orthorexia nervosa (ON) refers to an intense desire to consume healthy or biologi-
cally pure food that is free of articial products. ON is not regarded as a separate
eating disorder, but its clinical presentation shares common features with obsessi-
ve-compulsive disorder (OCD) and eating disorders. The current study examined 130
patients who were diagnosed with OCD (n = 49), panic disorder (n = 44), and genera-
lized anxiety disorder (n = 37). PaduaInventory WashingtonState UniversityRevisi-
on(PI-WSUR), The Eating Attitudes Test-40 (EAT-40), and the ORTO-11 test were given
to the participants. There were no signicant dierences between patient groups in
the mean scores of eating attitudes and orthorexia symptom severity. No signicant
association between ORTO-11 scores and body mass index was noted. Moderate
correlations (r > 0.30) were obtained between orthorexia symptom severity and ob-
sessive-compulsive symptom severity, EAT-40 total score, and checking and dressing/
grooming compulsions. These ndings suggest that ON, a pathological inclination
towards an obsession with healthy eating, is not specically associated with any of the
investigated illness groups. However, it has moderate correlations with the ritualistic
signs of OCD. Underlying worry may predispose people to develop a compulsion to
create the pure diet.
Key words: OCD, orthorexia, checking
ÖZET
Yaygın Anksiyete Bozukluğu, Panik Bozukluk ve Obsesif Kompulsif Bozukluk
Hastalarında Ortoreksi ile Obsesif Kompulsif Semptomlar Arasındaki İlişkinin
Araştırılması
Ortoreksiya nervoza (ON) içinde katkı maddeleri bulundurmayan, sağlıklı ya da biyo-
lojik olarak saf ürünleri tüketmek için duyulan yoğun bir isteği ifade eder. ON ayrı bir
yeme bozukluğu olarak kabul edilmemekle birlikte, klinik görünümü obsesif kompülsif
bozukluk (OKB) ve yeme bozukluklarıyla benzerlik göstermektedir. Bu çalışma OKB (n
= 42), panik bozukluk (n = 33), ve yaygın anksiyete bozukluğu (n = 25) tanısı konulan
100 hastayı incelemektedir. Katılımcılara Padua Envanteri- Washington Eyalet Üniver-
sitesi Revizyonu (PI-R), Yeme Tutumları Testi-40 (EAT-40) ve ORTO-11 testi uygulandı.
Hasta grupları arasında yeme tutumu ve ortoreksi belirti şiddeti ortalama skorları
açısından anlamlı farklılık saptanmadı. ORTO-11 skorları ve beden-kitle indeksi ara-
sında anlamlı bir ilişki bulunmadı. Ortoreksi belirti şiddeti ile obsesif kompülsif belirti
şiddeti, EAT-40 toplam skoru, ve kontrol etme ve giyinme/hazırlanma kompülsiyonları
arasında orta düzeyde korelasyon (r > 0.30) saptandı. Bu bulgular ON’nın sağlıklı yeme
obsesyonuna yönelik bir patolojik eğilim olduğunu ve araştırılan diğer hastalık grupla-
rı ile spesik olarak ilişkili olmadığını göstermektedir. Bununla birlikte, OKB’nin ritüe-
listik bulguları ile orta düzeyde korelasyonu bulunmaktadır. Altta yatan endişe, birey-
lerde saf ve katkısız diyet hazırlanmasına neden olan kompülsiyonun açığa çıkmasını
kolaylaştırabilir.
Anahtar sözcükler: OKB, ortoreksiya, kontrol etme
Araştırma Makalesi DOI: 10.5455/NYS.20160324065040Kısa Araştırma Raporu

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23
INTRODUCTION
Orthorexia nervosa (ON) is a new concept that desc-
ribes a strong preoccupation with healthy eating. It
manifests as the avoidance of foods or ingredients
containing additives or preservatives.1 Orthorexic phe-
nomenon can be seen as a continuum of states from
the healthy behaviour to the pathological interest on
healthy food and seems to be prevalent in especially
high risk populations. The term orthorexia nervosa
should be used only for the pathological condition. The-
re is limited epidemiological information on ON. Fidan
et al.2 used the ORTO-11 and found a 43.6 % tendency
rate among medical students. Ramacciotti et al.3 found
57.6 % prevalence of ON measured by ORTO-15 in their
sample of the general population. Whether orthorexic
behaviors prevalent in the population are clinically sigi-
nicant is unclear but it seems to be in close relation
with eating diorders and further investigations are nee-
ded in order to understand the impact of orthorexia on
the course of eating disorders.
The main characteristic of orthorexia is not a weight
loss obsession but rather a strong phobia about eating
only biologically pure food, yet severe weight loss and
malnutrition can occur due to selective eating, and this
may follow a course that resembles anorexia nervosa
(AN).4 Bratman1 contends that the main preoccupation
in ON is the food quality rather than quantity, yet the
dierential diagnosis is not always easy. For example,
during the course of AN, patients might become con-
cerned with the type of food they eat or may use ort-
horexic explanations to mask their true motivation for
weight loss.5 Orthorexia nervosa has indeed overlap-
ping aspects with anorexia nervosa (AN) and bulimia
nervosa (BN). Orthorexia symptoms has been found to
be highly prevalent among patients with AN and buli-
mia nervosa (BN) and was associated both with the cli-
nical improvement of AN and BN and tend to increase
after treatment.6 There are phenomenological similari-
ties between obsessive-compulsive disorder (OCD) and
eating disorders (EDs), such as the obsessional anxiety
that leads to a variety of ritualistic behaviors during
meal planning and preparation. As a result, meal pre-
paration can take quite a lot of time and may comprise
ritualistic features such as whether wooden or ceramic
materials are used in the preparation of foods,4 rep-
resenting compulsive behaviors. Similarly, a common
feature of OCD is the thought that catastrophic outco-
mes would occur that are in proportion with the percei-
ved threat if ritualistic behaviors cannot be completed.7
This feature may also be present in people with ON, as
they may feel guilty if they are not adherent enough
to their rules for healthy eating. Several studies indi-
cate a relationship between orthorexia and obsessive
traits in the normal population.8,9 However, no study
has investigated this association in a clinical sample.
Therefore, the current study aimed to identify whether
people with anxiety disorders and OCD are inclined
towards an excessive preoccupation with consuming
healthy food. We hypothesized that we would nd hi-
gher orthorexia scores in patients with higher scores
of obsessive-compulsive symptomatology. Considering
the phenomenological overlap between obsessions
and worry, patients with generalised anxiety disorder
and panic disorder were included in the present study
to have an inkling whether orthorexia might be speci-
cally linked to obsessing (if higher scores of orthorexia
would nd in OCD) or worrying (if higher scores of ort-
horexia would nd in generalised anxiety disorder or
panic disorder).
MATERIALS AND METHODS
This research study was approved by the Istanbul Uni-
versity, Cerrahpaşa Medical Faculty’s Ethics Committee,
and all participants provided written informed consent.
This was a cross-sectional study with 130 patients (97
women, mean age ± SD = 33.95 ± 10.59; 33 men, mean
age ± SD = 31.31 ± 9.98). All patients attended the out-
patient unit of Cerrahpaşa Medical Faculty Department
of Psychiatry, and were diagnosed with generalized
anxiety disorder (GAD), OCD, and panic disorder (PD).
The diagnosis was established by a psychiatrist accor-
ding to DSM-IV criteria.10 All patients were on pharma-
cological treatment of at least 12 weeks with recom-
mended rst-line medications for OCD and anxiety
disorders including SSRIs and clomipramine, with pos-
sible augmentation strategies including antipsychotics
during the study. Orthorexic behavior was assessed
using the ORTO-11 test, an adaptation of the ORTO-15
into Turkish,8 in which lower scores indicate greater
orthorexic behaviors. Patients were also assessed with
the Eating Attitudes Test (EAT)-40,11 developed to me-
asure the risk for eating disorders. Savaşır and Erol12
conducted a reliability and validity study of the EAT-40
Turkish version. A score greater than 30 is considered
to be an indicator of anorexic disorder.
The Padua Inventory-Washington State University Revi-
sion (PI-WSUR), a 41-item self-report measure of obses-
sions and compulsions,13 was also used. The PI-WSUR
consists of 5 subscales: obsessional impulses to harm
self/others, contamination obsessions and washing
compulsions, checking compulsions, obsessional thou-
ghts of harm to self/others, and dressing/grooming
compulsions. The translation of the Turkish version of
the PI-R was done by Yorulmaz et al.14 Weight and he-
ight of all patients were measured, and body mass in-
dex (BMI) was calculated using the weight in kilograms
divided by the square of height in meters.
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Statistical analysis
The Kolmogorov-Smirnov and Shapiro-Wilk tests were
used to determine normal distribution of the data.
One-way ANOVA and Kruskal-Wallis tests were used to
assess dierences in group means. Pearson two-tailed
correlations and Spearman correlation analyis were
computed between scores on the ORTO-11, EAT-40,
PI-WISUR, and BMI. Finally, we explored if controlling
for BMI inuenced any of these correlations. Statistical
signicance was set at p < 0.05 for group comparisons
and for correlation analyses. Statistical analyses were
carried out using SPSS version 15 for Windows.
RESULTS
The three patient groups did not dier signicantly
with respect to age, gender, education, and BMI (Tab-
le 1). Female gender was predominant in all groups.
The average BMI for men was 25.31 ± 4.22, and for
women it was 25.46 ± 5.43. There was no signicant
dierence between groups in the mean scores of ea-
ting attitudes (p = 0.251) or orthorexia symptom se-
verity (p = 0.948). Obsessive-compulsive symptom se-
verity was higher in the OCD group. The three patient
groups did not dier with respect to checking compul-
sions (p = 0.261), dressing/grooming compulsions (p
= 0.667), obsessional thoughts of harm to self/others
(p = 0.338), and obsessional impulses to harm self/ot-
hers (p = 0.167). The measure of obsession/compulsi-
ons related to contaminations was signicantly higher
in patients with OCD (p = 0.008). Pearson two-tailed
correlations were calculated to determine the relati-
onship between orthorexia and obsessive-compulsive
symptoms and eating attitudes. Moderate correlati-
ons (r > 0.30) were obtained for orthorexia symptom
severity with obsessive-compulsive symptom severity
and EAT-40 total score. Among the OCD subscales,
checking and dressing/grooming compulsions showed
the most signicant correlations with the ORTO-11
total score. Correlations are given in Table 2. Control-
ling for BMI did not change any of these correlations.
DOI: 10.5455/NYS.20160324065040Kısa Araştırma Raporu
Table 1. Sociodemographic and clinical features of the participants
OCD (N=49) GAD (N=37) PD (N=44) p F
Age 31.37±10.97 35.03±9.58 33.43±9.96 0.217
Gender Female=36
Male=13
Female=31
Male=6
Female=30
Male=14 0.143 X2=3.88
Education
(years)
9.92±3.8 9.86±3.91 9.82±3.34 0,998
BMI*
female
male
24.91±3.7 26.07±5,3 24.95±4,82 0,511 0.675
PI-WSUR* 55,98±28.75 36.84±21.88 47.32±28.3 0.018 4.11
EAT-40 12.04±6.31 13.86±6.01 14.22±7.9 0.251
ORTO-11* 28.4±5.76 28.4±5.69 28±7.3 0.948 0.054
*One-way ANOVA test was used.
Table 2. Correlations between ORTO-11, OCD total, EAT-40 total, and OCD subscales.
PI-WSUR
total
EAT-40
total
Contamination
obsessions and
washing com-
pulsions
Dressing/
grooming
compulsions
Checking
compulsions
Obsessional
thoughts of
harm to self/
others
Obsessional im-
pulses to harm
self/others
ORTO-11
total score
R-0.342 -0.339 -0.355 -0.485 -0.410 -0.235 -0.155
P<0.001 <0.001 <0.001 <0.001 <0.001 0.007 0.078
Pearson two-tailed correlation analysis was performed. Signicance was set to P < 0.01.
Abbreviations: OCD, obsessive-compulsive disorder; EAT, Eating Attitudes Test; PI-WSUR, Padua Inventory-Was-
hington State University Revision.

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DISCUSSION
In the current study, no signicant dierences were
found between patients with GAD, PD, or OCD with re-
gard to eating attitudes and orthorexia symptom seve-
rity. Orthorexia symptom severity did not dier signi-
cantly between the three groups. In this study BMI of
patients were within the normal-overweigt limits which
supports the view that even though people show ortho-
rexia features their main motivation is not weight loss.
Most studies have found no association between ON
and BMI.2,8 However, there was a signicant correlation
between EAT-40 scores and the ORTO-11, which indi-
cates that there is an association between orthorexia
and disordered eating behaviors and attitudes. In our
study patients did not score above 30 on EAT-40 which
suggests that the study sample was a lower risk popu-
lation for eating disorders. Thus, a tendency towards
preoccupation with eating or weight may be associated
with a tendency towards healthy eating.
In this study higher obsessive-compulsive scores were
associated with lower scores on ORTO-11, thus indica-
ting a higher tendency for orthorexia. Arusoĝlu et al.8
showed that obsessive-compulsive symptoms had a
signicant eect on orthorexic tendency (measured
with ORTO-11), such that individuals who had higher
obsessive-compulsive symptoms had greater ortho-
rexic tendencies. The most meaningful correlations we
obtained were between the ORTO-11 score and chec-
king and dressing/grooming compulsions. The cogniti-
ve interpretation of OCD suggests that compulsive che-
cking is associated with the belief that one has a special
or heightened responsibility for preventing harm to
others. Increased responsibility, probability of harm,
and anticipated seriousness of harm are three major
determinants of checking behaviors.15 Checking beha-
viors is carried out to protect people from harm; hence,
they are accepted as a form of preventive behavior.15
This is similar to the cognitive processes and behaviors
associated with the prevention of unhealthy food inta-
ke in ON, all of which result from unrealistic worry. The
dressing/grooming compulsions represent the urge to
insist on doing hygiene steps in a xed sequence. If the
sequence is interrupted, patients may again start at the
beginning, which suggests a phenomenological simi-
larity with the ritualistic behavior of preparing food in
people with ON. A hypothesis might be that an inclina-
tion towards an obsession with healthy eating might be
associated with the cognitive dimension of anxiety sen-
sitivity which has most frequently been associated with
pathological worry such as that which occurs in GAD.16
The current scales are insucient to assess obsessive
traits in subjects with orthorexic traits. Donini et al.9
concluded that the ORTO-15 has a notable predictive
capability concerning healthy eating behavior, while it
is less ecient in discriminating the presence of obses-
sive traits. Better scales may further clarify enlighten
obsessive-compulsive traits. Another limitation of the
study was the absence of a control group. Also men
were underrepresentative in the sample. Perhaps dif-
ferences between groups might have been masked
by having males and females combined. Exploring ob-
sessive-compulsive traits such as perfectionism could
enlighten the impact of obsessive-compulsive traits on
orthorexic behaviors. Further investigations should fo-
cus on the eects of obsessive traits on healthy eating
obsessions. Also, in this cohort as all patients were on
treatment, we do not know the eects of treatments
over orthorexia. A better understanding of underlying
cognitive processes may enhance the ecacy of cogni-
tive-behavioral therapies in people with ON.
CONCLUSIONS
The study suggests that ON severity was not found hig-
her in any of the investigated illness groups. However,
lack of control group limited us to draw a conclusion
meaningful correlations were obtained between the
ORTO-11 score and checking and dressing/grooming
compulsions, suggesting parallel cognitive processes
with the ritualistic compulsions. Underlying thought
processes such as anxiety due to increased responsibi-
lity may predispose people to develop a compulsion to
eat a pure diet.
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