AraştırmaKısa Araştırma Makalesi Raporu DOI: 10.5455/NYS.2015122102525910.5455/NYS.20160324065040

Relationship between Orthorexia and Obsessive-Compulsive Symptoms in Patients with Generalised Disorder, Panic Disorder and Obsessive Compulsive Disorder

Cana Aksoy Poyraz1, ABSTRACT Ebru Yücel Tüfekçioğlu2, Armağan Özdemir3, Orthorexia nervosa (ON) refers to an intense desire to consume healthy or biologi- Alper Baş4, cally pure food that is free of artificial products. ON is not regarded as a separate Ayşe Sakallı Kani4, , but its clinical presentation shares common features with obsessi- Ethem Erginöz5, ve-compulsive disorder (OCD) and eating disorders. The current study examined 130 Alaattin Duran6 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- 1Psychiatrist, 4Resident, 6Professor, on (PI-WSUR), The Eating Attitudes Test-40 (EAT-40), and the ORTO-11 test were given Istanbul University Cerrahpaşa to the participants. There were no significant differences between patient groups in Medical School, Department of the mean scores of eating attitudes and orthorexia symptom severity. No significant Psychiatry, Istanbul association between ORTO-11 scores and body mass index was noted. Moderate correlations (r > 0.30) were obtained between orthorexia symptom severity and ob- 2 5 Resident, Professor, Istanbul Uni- sessive-compulsive symptom severity, EAT-40 total score, and checking and dressing/ versity Cerrahpaşa Medical School, grooming compulsions. These findings suggest that ON, a pathological inclination Department of Public Health, Istan- towards an obsession with healthy eating, is not specifically associated with any of the bul, investigated illness groups. However, it has moderate correlations with the ritualistic 3Psychiatrist, Bakırköy Mental signs of OCD. Underlying worry may predispose people to develop a compulsion to Health and Neurological Diseases create the pure . Training and Research Hospital, Key words: OCD, orthorexia, checking Istanbul ÖZET Corresponding Author: Cana Aksoy Poyraz, Psychiatrist, Istanbul Uni- Yaygın Anksiyete Bozukluğu, Panik Bozukluk ve Obsesif Kompulsif Bozukluk versity Cerrahpaşa Medical School, Hastalarında Ortoreksi ile Obsesif Kompulsif Semptomlar Arasındaki İlişkinin Department of Psychiatry, Istanbul. Araştırılması

Phone: +90 532 715 95 04 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 E-mail: [email protected] yeme bozukluğu olarak kabul edilmemekle birlikte, klinik görünümü obsesif kompülsif Date of Receipt: 04 June 2015 bozukluk (OKB) ve yeme bozukluklarıyla benzerlik göstermektedir. Bu çalışma OKB (n = 42), panik bozukluk (n = 33), ve yaygın anksiyete bozukluğu (n = 25) tanısı konulan Date of Acceptance: 13 December 100 hastayı incelemektedir. Katılımcılara Padua Envanteri - Washington Eyalet Üniver- 2015 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 spesifik 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

Yeni Symposium • www.yenisymposium.com 22 Aralık 2015 • Cilt: 53 • Sayı: 4 Kısa Araştırma Raporu DOI: 10.5455/NYS.20160324065040

INTRODUCTION traits in the normal population.8,9 However, no study has investigated this association in a clinical sample. Orthorexia nervosa (ON) is a new concept that desc- Therefore, the current study aimed to identify whether ribes a strong preoccupation with healthy eating. It people with anxiety disorders and OCD are inclined manifests as the avoidance of foods or ingredients towards an excessive preoccupation with consuming 1 containing additives or preservatives. Orthorexic phe- healthy food. We hypothesized that we would find hi- nomenon can be seen as a continuum of states from gher orthorexia scores in patients with higher scores the healthy behaviour to the pathological interest on of obsessive-compulsive symptomatology. Considering healthy food and seems to be prevalent in especially the phenomenological overlap between obsessions high risk populations. The term orthorexia nervosa and worry, patients with generalised anxiety disorder should be used only for the pathological condition. The- and panic disorder were included in the present study re is limited epidemiological information on ON. Fidan to have an inkling whether orthorexia might be specifi- 2 et al. used the ORTO-11 and found a 43.6 % tendency cally linked to obsessing (if higher scores of orthorexia 3 rate among medical students. Ramacciotti et al. found would find in OCD) or worrying (if higher scores of ort- 57.6 % prevalence of ON measured by ORTO-15 in their horexia would find in generalised anxiety disorder or sample of the general population. Whether orthorexic panic disorder). behaviors prevalent in the population are clinically sigi- nificant is unclear but it seems to be in close relation MATERIALS AND METHODS with eating diorders and further investigations are nee- ded in order to understand the impact of orthorexia on This research study was approved by the Istanbul Uni- the course of eating disorders. versity, Cerrahpaşa Medical Faculty’s Ethics Committee, and all participants provided written informed consent. The main characteristic of orthorexia is not a weight This was a cross-sectional study with 130 patients (97 loss obsession but rather a strong phobia about eating women, mean age ± SD = 33.95 ± 10.59; 33 men, mean only biologically pure food, yet severe weight loss and age ± SD = 31.31 ± 9.98). All patients attended the out- can occur due to selective eating, and this patient unit of Cerrahpaşa Medical Faculty Department may follow a course that resembles of Psychiatry, and were diagnosed with generalized (AN).4 Bratman1 contends that the main preoccupation anxiety disorder (GAD), OCD, and panic disorder (PD). in ON is the food quality rather than quantity, yet the The diagnosis was established by a psychiatrist accor- differential diagnosis is not always easy. For example, ding to DSM-IV criteria.10 All patients were on pharma- during the course of AN, patients might become con- cological treatment of at least 12 weeks with recom- cerned with the type of food they eat or may use ort- mended first-line medications for OCD and anxiety horexic explanations to mask their true motivation for disorders including SSRIs and clomipramine, with pos- weight loss.5 Orthorexia nervosa has indeed overlap- sible augmentation strategies including antipsychotics ping aspects with anorexia nervosa (AN) and bulimia during the study. Orthorexic behavior was assessed nervosa (BN). Orthorexia symptoms has been found to using the ORTO-11 test, an adaptation of the ORTO-15 be highly prevalent among patients with AN and buli- into Turkish,8 in which lower scores indicate greater mia nervosa (BN) and was associated both with the cli- orthorexic behaviors. Patients were also assessed with nical improvement of AN and BN and tend to increase the Eating Attitudes Test (EAT)-40,11 developed to me- after treatment.6 There are phenomenological similari- asure the risk for eating disorders. Savaşır and Erol12 ties between obsessive-compulsive disorder (OCD) and conducted a reliability and validity study of the EAT-40 eating disorders (EDs), such as the obsessional anxiety Turkish version. A score greater than 30 is considered that leads to a variety of ritualistic behaviors during to be an indicator of anorexic disorder. meal planning and preparation. As a result, meal pre- paration can take quite a lot of time and may comprise The Padua Inventory-Washington State University Revi- ritualistic features such as whether wooden or ceramic sion (PI-WSUR), a 41-item self-report measure of obses- 13 materials are used in the preparation of foods,4 rep- sions and compulsions, was also used. The PI-WSUR resenting compulsive behaviors. Similarly, a common consists of 5 subscales: obsessional impulses to harm feature of OCD is the thought that catastrophic outco- self/others, contamination obsessions and washing mes would occur that are in proportion with the percei- compulsions, checking compulsions, obsessional thou- ved threat if ritualistic behaviors cannot be completed.7 ghts of harm to self/others, and dressing/grooming This feature may also be present in people with ON, as compulsions. The translation of the Turkish version of 14 they may feel guilty if they are not adherent enough the PI-R was done by Yorulmaz et al. Weight and he- to their rules for healthy eating. Several studies indi- ight of all patients were measured, and body mass in- cate a relationship between orthorexia and obsessive dex (BMI) was calculated using the weight in kilograms divided by the square of height in meters.

Yeni Symposium • www.yenisymposium.com 23 Aralık 2015 • Cilt: 53 • Sayı: 4 Kısa Araştırma Raporu DOI: 10.5455/NYS.20160324065040

Statistical analysis ting attitudes (p = 0.251) or orthorexia symptom se- verity (p = 0.948). Obsessive-compulsive symptom se- The Kolmogorov-Smirnov and Shapiro-Wilk tests were verity was higher in the OCD group. The three patient used to determine normal distribution of the data. groups did not differ with respect to checking compul- One-way ANOVA and Kruskal-Wallis tests were used to sions (p = 0.261), dressing/grooming compulsions (p assess differences in group means. Pearson two-tailed = 0.667), obsessional thoughts of harm to self/others correlations and Spearman correlation analyis were (p = 0.338), and obsessional impulses to harm self/ot- computed between scores on the ORTO-11, EAT-40, hers (p = 0.167). The measure of obsession/compulsi- PI-WISUR, and BMI. Finally, we explored if controlling ons related to contaminations was significantly higher for BMI influenced any of these correlations. Statistical in patients with OCD (p = 0.008). Pearson two-tailed significance was set at p < 0.05 for group comparisons correlations were calculated to determine the relati- and for correlation analyses. Statistical analyses were onship between orthorexia and obsessive-compulsive carried out using SPSS version 15 for Windows. symptoms and eating attitudes. Moderate correlati- ons (r > 0.30) were obtained for orthorexia symptom RESULTS severity with obsessive-compulsive symptom severity The three patient groups did not differ significantly and EAT-40 total score. Among the OCD subscales, with respect to age, gender, education, and BMI (Tab- checking and dressing/grooming compulsions showed le 1). Female gender was predominant in all groups. the most significant correlations with the ORTO-11 The average BMI for men was 25.31 ± 4.22, and for total score. Correlations are given in Table 2. Control- women it was 25.46 ± 5.43. There was no significant ling for BMI did not change any of these correlations. difference between groups in the mean scores of ea-

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 Female=36 Female=31 Female=30 Gender 0.143 X 3.88 Male=13 Male=6 Male=14 2= Education 9.92±3.8 9.86±3.91 9.82±3.34 0,998 (years) BMI* 24.91±3.7 26.07±5,3 24.95±4,82 0,511 0.675 female male 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.

Contamination Obsessional Dressing/ Obsessional im- PI-WSUR EAT-40 obsessions and Checking thoughts of grooming pulses to harm total total washing com- compulsions harm to self/ compulsions self/others pulsions others

R -0.342 -0.339 -0.355 -0.485 -0.410 -0.235 -0.155

ORTO-11 total score P <0.001 <0.001 <0.001 <0.001 <0.001 0.007 0.078

Pearson two-tailed correlation analysis was performed. Significance was set to P < 0.01. Abbreviations: OCD, obsessive-compulsive disorder; EAT, Eating Attitudes Test; PI-WSUR, Padua Inventory-Was- hington State University Revision.

Yeni Symposium • www.yenisymposium.com 24 Aralık 2015 • Cilt: 53 • Sayı: 4 Kısa Araştırma Raporu DOI: 10.5455/NYS.20160324065040

DISCUSSION capability concerning healthy eating behavior, while it is less efficient in discriminating the presence of obses- In the current study, no significant differences were sive traits. Better scales may further clarify enlighten found between patients with GAD, PD, or OCD with re- obsessive-compulsive traits. Another limitation of the gard to eating attitudes and orthorexia symptom seve- study was the absence of a control group. Also men rity. Orthorexia symptom severity did not differ signifi- were underrepresentative in the sample. Perhaps dif- cantly between the three groups. In this study BMI of ferences between groups might have been masked patients were within the normal-overweigt limits which by having males and females combined. Exploring ob- supports the view that even though people show ortho- sessive-compulsive traits such as perfectionism could rexia features their main motivation is not weight loss. enlighten the impact of obsessive-compulsive traits on Most studies have found no association between ON orthorexic behaviors. Further investigations should fo- 2,8 and BMI. However, there was a significant correlation cus on the effects of obsessive traits on healthy eating between EAT-40 scores and the ORTO-11, which indi- obsessions. Also, in this cohort as all patients were on cates that there is an association between orthorexia treatment, we do not know the effects of treatments and disordered eating behaviors and attitudes. In our over orthorexia. A better understanding of underlying study patients did not score above 30 on EAT-40 which cognitive processes may enhance the efficacy of cogni- suggests that the study sample was a lower risk popu- tive-behavioral therapies in people with ON. lation for eating disorders. Thus, a tendency towards preoccupation with eating or weight may be associated CONCLUSIONS with a tendency towards healthy eating. The study suggests that ON severity was not found hig- In this study higher obsessive-compulsive scores were her in any of the investigated illness groups. However, associated with lower scores on ORTO-11, thus indica- lack of control group limited us to draw a conclusion ting a higher tendency for orthorexia. Arusoĝlu et al.8 meaningful correlations were obtained between the showed that obsessive-compulsive symptoms had a ORTO-11 score and checking and dressing/grooming significant effect on orthorexic tendency (measured compulsions, suggesting parallel cognitive processes with ORTO-11), such that individuals who had higher with the ritualistic compulsions. Underlying thought obsessive-compulsive symptoms had greater ortho- processes such as anxiety due to increased responsibi- rexic tendencies. The most meaningful correlations we lity may predispose people to develop a compulsion to obtained were between the ORTO-11 score and chec- eat a pure diet. king and dressing/grooming compulsions. The cogniti- ve interpretation of OCD suggests that compulsive che- REFERENCES cking is associated with the belief that one has a special 1. Bratman S. Original essay on orthorexia. 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Yeni Symposium • www.yenisymposium.com 25 Aralık 2015 • Cilt: 53 • Sayı: 4 Kısa Araştırma Raporu DOI: 10.5455/NYS.20160324065040

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Yeni Symposium • www.yenisymposium.com 26 Aralık 2015 • Cilt: 53 • Sayı: 4