What if my child also has anxiety or OCD alongside the eating disorder?

Published by Unseen Progress, an independent publisher of caregiver research. Last reviewed 2026-05-10. Part of the adolescent eating disorder research overview.

Short answer. Comorbid anxiety and OCD in adolescent anorexia are more common than not — population estimates run from roughly 50% to 75% across cohorts (Kaye et al., 2004; Swinbourne & Touyz, 2007). The clinical literature treats the comorbidity as the rule rather than the exception, and the research-backed approach sequences treatment: weight restoration first, comorbid anxiety/OCD work largely after, with stabilisation of acute symptoms in parallel where needed (NICE, 2020; AED, 2021). Family accommodation patterns from anxiety and OCD overlap meaningfully with FBT meal dynamics, and recognising the overlap helps both treatments.

What the research says about the prevalence

Comorbid anxiety disorders — generalised anxiety, social anxiety, separation anxiety — and OCD are documented at high rates across adolescent anorexia cohorts. Kaye and colleagues' large multi-site analysis found that roughly two-thirds of patients with anorexia met lifetime criteria for at least one anxiety disorder, with the anxiety disorder typically pre-dating the eating disorder by years (Kaye et al., 2004). Swinbourne and Touyz's review confirmed the pattern across multiple datasets and reported elevated rates of OCD specifically (Swinbourne & Touyz, 2007).

The pattern is so consistent that current guidelines treat comorbid anxiety and OCD as expected. NICE NG69 (2020) and the AED Medical Care Standards (AED, 2021) explicitly address the comorbidity profile in their treatment recommendations.

Why the comorbidity matters for treatment

Two structural features make the comorbidity meaningful for clinical decisions.

1. Anxiety and OCD intensify under starvation

The cognitive and affective consequences of caloric restriction — narrowed cognitive flexibility, intensified rumination, heightened fear responses — make pre-existing anxiety and OCD worse during the active phase of an eating disorder. A child whose anxiety was manageable before may present with severe anxiety during low-weight anorexia, and the severity is partly a function of the under-fuelled brain rather than a worsening of the underlying anxiety disorder.

The clinical implication is that some apparent anxiety and OCD symptoms remit with weight restoration alone — they were amplified by starvation and recede as the brain re-fuels (NICE, 2020; AED, 2021). This is one reason the guidelines sequence treatment: doing anxiety/OCD work on a malnourished brain is both less effective and less informative about what the underlying disorder actually looks like at restored weight.

2. Family accommodation overlaps across conditions

Family accommodation — parents adjusting routines, environments, and language to reduce a child's distress — is a recognised feature of childhood anxiety and OCD treatment, and one of the strongest predictors of treatment outcome (Lebowitz et al., 2014). The same dynamic operates in FBT but with different content: parents accommodating the eating disorder's rules instead of (or in addition to) the anxiety or OCD's rules.

This overlap is operationally useful. Parents who learn to recognise accommodation in one domain often see it more clearly in the other. A parent who has been doing FBT for six months has typically developed considerable skill at not-accommodating the eating disorder's demands; that skill transfers to anxiety and OCD work in Phase 3.

What the research suggests about sequencing

The clinical literature converges on a sequencing approach.

During Phase 1 (weight restoration)

  • Treat acute anxiety and OCD symptoms enough to enable refeeding to proceed. Severe anxiety attacks at the table, severe OCD rituals around food preparation, or panic that prevents medical follow-up all need addressing in parallel with refeeding.
  • Do not start a new course of CBT for anxiety or OCD during active starvation. The malnourished brain does not reliably respond to cognitive therapy, and the parallel treatment surface adds load (NICE, 2020).
  • Continue established treatments. A child who was on stable SSRI medication for anxiety or OCD before the eating disorder is typically continued on it, with paediatric oversight.
  • Use externalisation broadly. Parents who externalise both the eating disorder and the anxiety/OCD ("the anorexia is loud at this meal", "the OCD is asking you to do that ritual right now") give the child a frame for several illnesses at once without conflating them.

During Phase 2 (autonomy transfer)

  • Begin to assess what anxiety and OCD symptoms remain at restored weight. Symptoms that recede with weight restoration mark the starvation-related amplification; symptoms that persist mark the underlying disorder.
  • Plan for anxiety/OCD-specific treatment based on what remains. Cognitive behaviour therapy with exposure work is the leading evidence-based approach for both conditions in adolescents (Walkup et al., 2008; Storch et al., 2007 for OCD).

During Phase 3 (consolidation)

  • Initiate or continue anxiety/OCD-specific treatment. This is the phase the original FBT manual reserves for adolescent developmental work, and where treatment for comorbid conditions can land effectively now that the brain is re-fuelled.
  • Maintain the externalisation framework across illnesses; the integrated frame remains useful well beyond Phase 1.

What the research suggests not doing

  • Do not delay refeeding to address anxiety or OCD first. This is the most consequential reversal of the research-backed sequence. Untreated low-weight anorexia is medically dangerous and cognitively disabling; addressing comorbid conditions on a starved brain is not effective. NICE NG69 (2020) is explicit on the sequencing.
  • Do not assume all anxiety symptoms during Phase 1 are "the anxiety disorder." A meaningful portion will remit with weight restoration. Treating them all as the underlying disorder leads to over-medication and over-pathologisation.
  • Do not stop established psychiatric medication unilaterally. Decisions about anxiety/OCD medication during Phase 1 are paediatric and psychiatric decisions made with the treatment team, not parental ones.
  • Do not use anxiety as a reason to not do FBT. Adolescents with severe anxiety or OCD comorbidity can do FBT and the trial evidence supports it (Lock et al., 2010); the comorbidity profile shapes the protocol's intensity, not whether it is delivered.

What the family-accommodation overlap means in practice

Lebowitz and colleagues' work on family accommodation in childhood anxiety has produced a parallel-track treatment for parents (SPACE — Supportive Parenting for Anxious Childhood Emotions) that addresses parental accommodation directly. The structural overlap with FBT is striking: in both cases, parental behaviour is the active treatment lever, and the clinical work is on what parents stop accommodating (Lebowitz et al., 2014).

This has two implications for families navigating both:

  • The skill is transferable. Parents who are doing FBT well are typically already practising the not-accommodating stance the anxiety/OCD work will require. They do not need to develop the skill from scratch in Phase 3.
  • The vocabulary is shared. "We're not going to do that ritual right now" works for OCD; "we're not going to renegotiate this plate right now" works for anorexia. The structural similarity helps parents hold a coherent frame across illnesses.

When comorbidity changes the treatment plan more substantially

A small set of comorbidity profiles change the FBT delivery meaningfully:

  • Severe OCD with food-contamination content can intersect with eating-disorder rules in ways that require careful disentangling. Direct exposure work may need to wait for Phase 3, but the meal-support strategies need to be calibrated by the team.
  • Co-occurring autism changes both the diagnostic picture (ARFID becomes a stronger differential) and the meal dynamics (sensory accommodations become more salient). Specialist input is typically required.
  • Severe depression with suicidality is a separate emergency and may require inpatient stabilisation before outpatient FBT can proceed (AED, 2021).
  • Trauma history — particularly in girls with abuse histories — can interact with the meal dynamics and benefit from trauma-informed adaptations of the FBT protocol.

Related questions

References

  • Kaye, W. H., Bulik, C. M., Thornton, L., Barbarich, N., & Masters, K. (2004). Comorbidity of anxiety disorders with anorexia and bulimia nervosa. American Journal of Psychiatry, 161(12), 2215–2221.
  • Swinbourne, J. M., & Touyz, S. W. (2007). The co-morbidity of eating disorders and anxiety disorders: a review. European Eating Disorders Review, 15(4), 253–274.
  • Lebowitz, E. R., Omer, H., Hermes, H., & Scahill, L. (2014). Parent training for childhood anxiety disorders: the SPACE program. Cognitive and Behavioral Practice, 21(4), 456–469.
  • National Institute for Health and Care Excellence (2020). Eating disorders: recognition and treatment (NG69).
  • Lock, J., & Le Grange, D. (2013). Treatment Manual for Anorexia Nervosa: A Family-Based Approach (2nd ed.). Guilford Press.

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