Exposure therapy is a widely recognized and effective treatment for OCD, but it may not work as effectively for EDs. Some of the reasons for poor delivery or treatment manual avoidance are known broadly, but hesitancy can be higher for ED clinicians specifically. EDs have a high mortality and self-harm rate and significant physiological comorbidities, making clinicians more hesitant to utilize certain interventions. Complexities such as starvation effects, the ego-syntonic presentation, and low motivation can compromise exposure therapy. There may be need for reassurance, safety behaviors, and distraction when the primary treatment goal is weight gain. Additionally, there are emotions outside of anxiety that are not effectively treated with exposure (i.e., guilt, disgust, anger). Uniquely, the fears and concerns associated with EDs are also present in the general population. Preoccupation with health, size, and weight is prevalent in society, which affects beliefs about the body and food. This may lead to clinicians overempathizing with patients and can affect the way they facilitate and process food and weight exposures during treatment, all complicating exposure therapy for EDs.

The treatment of underweight and malnourished individuals with eating disorders (EDs) and obsessive-compulsive disorder (OCD) poses unique challenges and considerations. Low weight and malnourishment have implications on symptom presentation, treatment course, and outcomes. Clinicians should consider the impact of malnourishment on organ systems, the importance of medical care in treatment, and dietary considerations for weight restoration. Restrictive eating disorders such as AN and atypical AN can lead to similar psychological effects of malnourishment even if not underweight. Current ED treatment programs consider all patients as having malnutrition effects due to their illness, regardless of BMI. Atypical AN often goes unnoticed, leading to reinforcement of disordered eating behavior. Chronic malnutrition and starvation can affect almost every major organ system and result in permanent damage or death if not addressed. Additionally, underweight or malnourished patients often have a lot of dietary needs and need a lot of calories for restoration, which can be complicated by OCD symptoms such as obsessionality and intolerance of uncertainty.