With Our Powers Combined: The Intersection of OCD and Food Allergy Anxiety

As if having obsessive-compulsive disorder (OCD) isn’t enough of a challenge on its own, having food allergies (or being a caregiver to someone with allergies) can be an area that OCD latches on to. When these two conditions combine, it can create an intense pairing in which each one is playing off the other, resulting in a stalemate worthy of a chess board. OCD provides the thinking structure and food allergy anxiety provides the fuel. That means the anxiety of living with a food allergy can become the topic of the obsession involved in OCD. The unique difficulty is in the fact that the intrusive thoughts/fears about food can have a realistic element, given the very real and potentially dangerous consequences of an allergen exposure. So how does one (either an individual or a treating therapist) navigate this dynamic duo?

OCD is a mental health disorder involving intrusive, unwanted thoughts, images, sensations, and urges along with corresponding physical or mental behaviors intended to alleviate distress. Compulsions can range from checking behaviors, avoidance, reassurance seeking, excessive mental review, excessive researching, repeating behaviors, etc. Food allergy anxiety is impairing anxiety related to living with (or being a caregiver to) someone with a food allergy/allergies. It can involve excessive/unnecessary restrictions that are out of proportion to the level of risk for that individual, which can lead to a greatly decreased quality of life. It can also include excessive and impairing physical anxiety symptoms when engaging in activities that could potentially lead to a reaction (eating, traveling, social gatherings, etc.).

What’s What?

While it isn’t always necessary from a treatment perspective to tease out the specific symptoms of two separate anxiety-based conditions when the treatments are similar, it can still be helpful to know the general differences. In this case, it is very important to know what can be treated as a symptom of a mental health condition and what needs to be treated as a reasonable and necessary precaution. OCD tends to have a history, pre-dating the food allergy (though not always) and usually involves a lot more repetition of safety behaviors, specific rituals, intrusive thoughts, and more (see specific examples of compulsions below).

Food allergy anxiety can develop at any time in life (typically after a food allergy reaction/diagnosis) and is usually less ritualistic than OCD. However, both conditions can include and safety behaviors/avoidance that due to their excessiveness or function, are not realistically connected to safety measures. Examples include:

• Excessive online research
• Excessive avoidance
• Excessive reassurance seeking
• Excessive rumination and distress (including panic symptoms)
• Excessive monitoring and hyperawareness of potential symptoms of an allergic reaction
• Excessive avoidance without a confirmed food allergy (for example, hearing that rarely someone can develop allergies later in life and then being avoidant of common allergens without actually having a history of an allergic reaction)

Are you seeing the trend here? The word ‘excessive’. That is when it goes from reasonable safety precaution to impairing one’s functioning. If you struggle with OCD and food allergy anxiety, it can be hard to tell what is excessive. That is why it may be important to have guidance from both a board-certified allergist and an educated OCD specialist to navigate these conditions together. 

The Dream Team

Ideally the OCD specialist and allergist will be in communication with one another to optimize treatment and ensure safety. This way, the OCD specialist can educate the allergist to help inform how they interact with that patient. At the same time, the OCD specialist can have a better understanding of the person’s individual food allergy to help inform how they create specific exposures. Exposure with response prevention (ERP) involves intentionally engaging with triggers so that one can practice managing distress without relying on compulsions. This is utilized in OCD treatment to help the sufferer learn that they can handle distress and don’t need their excessive safety behaviors and rituals to keep themselves safe. 

When it comes to obsessions about food allergies it is important that exposures challenge the boundaries of self-imposed excessive safety behaviors in a way that is not actually dangerous. For some individuals, it might be entirely safe to touch their allergen and then wash hands one time, or to be in the same room as someone shelling peanuts. But this can only be determined alongside someone’s allergist. It cannot be assumed to be safe, but it also cannot be assumed to be unsafe. Every individual’s needs are different. But who gets to make that decision? Your allergist. Not your OCD. 

Information is Power

When it comes to treating OCD and anxiety symptoms around food allergies, it is important to know the difference between IgE-mediated food allergies, non-IgE-mediated food allergies, and food intolerances. This distinction matters because it can shape what exposures might look like for each individual. One size does not fit all here! 

It is also worth understanding the method of food allergy diagnosis, as there are many people living with restrictions developed from outdated practices. For example, skin-prick and blood testing without a history of symptoms from ingestion can have a high rate of false positives (for example, someone can have IgE antibodies but no actual symptoms when exposed to an allergen). The current gold standard for diagnosing a food allergy is a history of reproducible reactions to consuming the food and/or, when appropriate, an in-office oral food challenge to consume a food while being observed by an allergist. Without those markers, people can be living with unnecessary restrictions and fears. 

Furthermore, it is important to have a good understanding of each individual’s personal history of reactions as well as what the current research says about food allergy reactions. There may be some surprises! For example:

• IgE-mediated allergy reactions will usually occur within minutes and very rarely will they occur longer than an hour or two later (Stukus et al., 2021)
• It is very rare for touching a food allergen to cause anaphylaxis (Stukus et al., 2021)
• It is extremely rare for someone to have an allergic reaction from being near or inhaling a food allergen (Stukus et al., 2021)

While medical emergencies can happen, if someone does not have a history of a concerning level of reaction to an allergen, they can tailor their level of precaution to their specific needs. This is more effective than establishing precaution levels based primarily on anxiety. Where one person might need to avoid even being in the presence of cooking seafood, another might not. That is a decision that should be based on objective facts, not subjective feelings. 

How Can OCD Manifest when Merged with Food Allergy Anxiety?

Examples of Possible Obsessions:

• Contamination obsessions around unseen allergen proteins and the possibility of cross-contamination
• Just right obsessions/perfectionism around checking/cleaning/treatment protocols
• Harm/self-harm obsessions: fears that one will cause a reaction in themselves or a loved one either accidentally or by acting on unwanted impulses 
• Health anxiety-like obsessions around symptoms of an allergic reaction (for example, excessive and impairing checking for symptoms of anaphylaxis or excessive unnecessary visits to a health provider or emergency department) 
• Moral scrupulosity obsessions around making sure one doesn’t accidentally cause an allergic reaction in others (for example, excessive worry about eating a potential allergen and then touching something in a public space etc.)
• Sensorimotor/hyperawareness obsessions related to body parts that could be involved in an allergic reaction (skin, stomach, throat, lungs, etc.)
• False memory obsessions around having consumed an allergen or served an allergen to a loved one
• Magical thinking obsessions (for example, "if I wear this shirt, then I’ll have a reaction today")

Examples of Possible Compulsions:

• Excessive washing/cleaning/sanitizing beyond necessary for food safety guidelines (for example, wiping down all groceries in case they came into contact with an allergen, or washing hands a specific number of times after touching an allergen etc.)
• Excessive checking for potential symptoms of a reaction 
• Checking one’s emotions after intrusive thoughts to see if one secretly wanted to cause harm to self or others via an allergen (for example, worrying that an accidental exposure occurred because you actually wanted to harm your child with their allergen)
• Avoiding preparing food for a loved one with food allergies
• Repeatedly asking for reassurance from others that one did not consume an allergen or serve an allergen to a loved one
• Repeating an action until it feels right (for example, re-reading ingredients or hand washing many times until it feels right, etc.)
• Completely avoiding activities such as social gatherings, travel, eating at a restaurant, allowing a child to go to school or a friend’s house, etc. 
• Excessive online research or excessive, repetitive questions to food manufacturers, servers, or allergist
• Excessive, repetitive checking for signs of a reaction
• Excessive, repetitive checking for epinephrine devices /expiration dates on epinephrine devices 
• Excessive rigidness, rituals, or reassurance seeking around treatment protocols 
• Excessive, anxiety-driven engagement with food allergy related articles or social media content
• Memory hoarding compulsions such as extreme tracking and reviewing of memories around having avoided an allergen properly or prepared food properly, etc.

How Do We Treat It?

• Exposure with response prevention (ERP): putting oneself in situations that trigger anxiety or discomfort and resisting urges to engage in compulsions/rituals (including mental rituals and avoidance) 
• Mindfulness: learning how to be present without judgement (including when experiencing anxiety) and how to develop attentional awareness skills
• Acceptance & commitment therapy: skills to increase cognitive flexibility and learn to accept/tolerate unpleasant thoughts and emotions

How ERP Can Be Modified

When food allergies are involved, safety precautions must be taken. A therapist should never ask someone to ingest their allergen (unless the person is engaged in oral immunotherapy or an oral food challenge, and under the care of a board-certified allergist), be without their epinephrine if prescribed, or do anything that the client’s allergist would not recommend. Here are a few things to consider when approaching ERP around food allergies:

• Work alongside a board-certified allergist to understand the realities of the specific allergy and what level of precaution is recommended for you specifically
• Take a goal-centered approach (what do you want to be doing more or less of?)
• What valued things or places are you avoiding due to your fears around food allergies? Are there ways to do those things or go to those places while staying safe from your allergens?
• Exposures can be simply avoiding food allergens in the same way as a responsible person who does not have OCD (aka what would someone without OCD do to avoid their allergen? They might double check the ingredients list on a food but probably wouldn’t read it six times)

Living with a food allergy, especially when you also have OCD/food allergy anxiety, can be scary stuff. But it doesn’t have to keep you from living a full life. Don’t let anxiety convince you that having a very real food allergy means you have to follow OCD’s made-up commands. And when anxiety blurs that line, reach out to people who can team up to help you manage both conditions and get you back to living your best.