The co-occurrence of Obsessive-Compulsive Disorder (OCD) and Avoidant/Restrictive Food Intake Disorder (ARFID) is increasingly recognised in clinical settings. While these two conditions may appear distinct at first glance, they share deeper psychological mechanisms that can blur diagnostic boundaries and complicate treatment. For individuals, families, and clinicians alike, recognising how these disorders interact is crucial to providing effective support.
OCD is a condition marked by intrusive, unwanted thoughts (obsessions) and repetitive behaviours or mental rituals (compulsions) performed to alleviate distress or prevent perceived harm. ARFID, meanwhile, is an eating disorder defined by a persistent failure to meet nutritional needs. Unlike other eating disorders, ARFID is not driven by body image concerns but by factors such as sensory sensitivities, low appetite, or fears of aversive consequences like choking, vomiting, or gastrointestinal distress.
At the heart of both OCD and ARFID lies anxiety-driven avoidance. For someone with OCD, food may become a trigger for contamination fears, moral concerns (e.g. “What if I harm someone by preparing this incorrectly?”), or fears of losing control. For someone with ARFID, the act of eating itself can provoke fear-based responses—particularly in the “aversive consequences” subtype, where there is a deep-seated fear of gagging, vomiting, or choking. While these patterns can develop separately, they often overlap.
In practice, clinicians might see a young person who refuses certain textures or food groups due to fear of becoming unwell. On the surface, it might look like ARFID. But a deeper assessment might reveal a network of obsessional thoughts and compulsive safety behaviours—mental checking, reassurance seeking, contamination rituals—that point to OCD. Alternatively, a person with longstanding OCD might begin to restrict their food intake so severely in response to intrusive thoughts that they meet full ARFID criteria.
This diagnostic complexity is compounded by the shared cognitive and emotional profile across the two disorders. Perfectionism, intolerance of uncertainty, black-and-white thinking, and heightened interoceptive sensitivity (e.g., hyper awareness of bodily sensations), often characterise both OCD and ARFID presentations. The individual may report needing to feel “just right” before eating, or insist on highly specific food preparation routines. They may struggle with distress when things feel unpredictable or unfamiliar, which can manifest in both food-related and non-food-related domains.
Another complicating factor is dealing with emotions like disgust, shame, and anticipatory anxiety, which also play a central role. Disgust, for example, can be particularly tricky in both disorders and does not typically respond well to traditional habituation-based exposure. Instead, treatment may need to focus on inhibitory learning, counterconditioning, or defusion-based approaches from Acceptance and Commitment Therapy (ACT) to help the person relate differently to the feeling rather than trying to eliminate it.
From a treatment standpoint, the overlap of OCD and ARFID calls for a flexible, nuanced approach. Exposure and Response Prevention (ERP), the gold standard treatment for OCD, can be adapted to address food-related fears. For example, ERP tasks might involve gradually reintroducing feared foods without engaging in compulsive behaviours such as excessive reassurance or checking expiration dates. However, when sensory avoidance or low appetite are also at play—as in ARFID—additional strategies from feeding therapy or CBT-E may be needed. This could include sensory integration, appetite awareness training, or parent-led meal support strategies.
Crucially, clinicians need to differentiate between compulsions (which are intended to prevent a feared outcome) and avoidance due to sensory discomfort or disinterest. A child refusing pasta because “it feels slimy and disgusting” may need a different intervention than one who refuses it because “what if I choke and die?” That said, the two can co-exist, and often do, particularly in neurodivergent populations.
Assessment should be careful and multi-dimensional. Relying solely on standard eating disorder screening tools or diagnostic checklists may result in misdiagnosis or partial formulations. A collaborative approach involving clinical interviews, behavioural observations, and parent/carer input is often essential. Attention should also be given to developmental history, sensory sensitivities, medical factors, and the presence of other anxiety symptoms.
When OCD and ARFID co-occur, they can reinforce one another. Avoidance reduces anxiety in the short term but deepens fear over time, shrinking the individual’s world and limiting social, emotional, and nutritional development. Early recognition and targeted treatment can help interrupt this cycle and support the person to build confidence, flexibility, and trust in their body.
Ultimately, understanding the link between OCD and ARFID is not just about diagnostic precision—it’s about empathy. It’s about recognising that beneath the rituals, the food refusal, the distress at the dinner table, is a person trying to navigate a world that feels threatening and unpredictable. With the right support, that world can gradually feel safer, more flexible, and more nourishing—in every sense of the word.
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