Treating comorbid obsessive-compulsive disorder and eating disorders can be complex as OCD symptoms such as rigidity, perfectionism, and reassurance seeking can disrupt typical ED interventions such as meal planning. Additionally, the content of a patient’s obsessions in OCD can shift to different categories in their life, including ED recovery (e.g., intrusive thoughts that they are going to relapse). To address the challenges of treating comorbid OCD and EDs, it is important to promote flexibility in various aspects of meal planning such as incorporating a variety of foods, being flexible with meal times, meal prepping, and promoting mindfulness and self-compassion. Cognitive techniques such as cognitive restructuring can be used to help patients identify and challenge rigid and perfectionistic thinking. Gradual exposure to flexibility can also be used to help patients learn to tolerate and manage their anxiety. A collaborative approach involving patients in the meal-planning process can also be helpful in reducing rigidity and promoting a more active role in decision-making.

This chapter provides dietitians with a TBT-S strategic approach when working with adult clients with AN. Structure is central strategically. Dietitians enhance empathy when aligning with clients’ AN traits. Meal planning for adults with AN needs to be practical, consistent, and structured regarding how to obtain and prepare foods. Support persons are treatment team members who need to learn the meal plan and strategies to provide assistance at home or work/school. After the meal plan is identified, the dietitian is a central agent in coaching, practicing pre-, post, and mealtime fuel intake with both the client and their Support(s) virtually or face-to-face.

There is a biological basis for why eating is not easy in that food is not intrinsically rewarding, contributing to why the brain may code food as harmful. Lack of motivation for treatment may reflect a deficit in biologically induced reward/motivation system rather than willfulness. Clinicians can help clients to turn to Supports and others to identify external motivators since they are unable to experience intrinsic motivation. Providing structure around meals is temperament congruent because it is unlikely that individuals with active AN can eat intuitively given altered brain reward signaling to hunger.

The Behavioral Agreement for severe-and-enduring clients with anorexia nervosa and its preparatory worksheets provide a structured-strategic plan of action for adult clients to practice collaboratively with their Support(s). It incorporates client and Support traits to determine what is realistic and unrealistic for long-term change.