Let’s talk about Autism and Eating Disorders

I am a trainee clinical psychologist trying to navigate my way through my third year of clinical training. When it came to deciding my long-scale research project, I was excited when an opportunity to combine two interests of mine came up. The more I researched into the link between eating disorders (ED) and autism, the more surprised I became at the prevalence of autistic traits in people struggling with an eating disorder, and the large proportion who go undiagnosed until they present to eating disorder clinics. Approximately 20% of people with an ED are autistic (Dattaro, 2020). Cognitive rigidity, attention to detail, sensory sensitivities, and poor social functioning, appear to be the most closely shared traits between the two conditions (Tchanturia et al., 2020).

A paper of particular interest looked at understanding the link between autism and eating disorders. Brede et al. (2020) interviewed autistic women with experience of Anorexia Nervosa (AN), parents and healthcare professionals, to understand how AN develops and persists in autistic people. Themes obtained from the interviews, allowed the researchers to develop an autism-specific model of restrictive eating difficulties, which suggests a direct and indirect pathway to developing restrictive eating in autistic individuals. The direct pathway suggests that the likelihood of extreme restrictive eating developing may be increased by autism-related challenges that focus around food and ED-related behaviours. The indirect pathway proposes that restrictive eating is utilised as a maladaptive coping mechanism to address the way in which autism-related challenges are thought to result in negative emotional consequences. Alongside this, external factors, such as bullying, being misunderstood and stressful life events, may play an important role in the indirect pathway. The researchers hypothesise that autistic people may develop restrictive eating behaviours as the effects reduce autism-related difficulties by allowing people to numb down emotional and sensory experiences and introduce calmness by obtaining a sense of control and predictability. This paper provides an insight into the autism-specific mechanisms underlying restrictive eating difficulties, through the first-hand accounts of individuals, families and clinicians.

Babb et al. (2021) used the same sample to investigate their experience of eating disorder services. Three themes emerged from the interviews: misunderstanding autism and autistic traits, one treatment does not fit all, and improving accessibility and engagement with services. Recommendations for future research suggest the need for developing tailored eating disorder interventions to specific needs for autistic people. As standard treatment is based on typical ED presentations and motivators, it is unsurprising that treatment outcomes are reported to be considerably worse if autism is present (Nielsen et al., 2015). These pieces of research are a step further into understanding the interconnected nature of these two conditions and recognising why standard eating disorder therapies may not be as effective for autistic individuals.

The PEACE pathway was developed to support the clinical comorbidity between autism and AN by improving autism identification, staff training, treatment modifications, and service-user experiences (Tchanturia et al., 2020). The aim is to improve clinician understanding and confidence in supporting autistic individuals with an eating disorder by implementing evidence-based strategies developed through the pathway. Reading about the PEACE pathway sparked my own interest in thinking about particular psychological therapies, such as Cognitive Behavioural Therapy for eating disorders (CBT-E) and the Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA), and how they could be tailored to support autistic people with an eating disorder. Studies which have adapted CBT for autistic people with other mental health conditions, such as social anxiety (Bemmer et al. 2021) have reported significant improvements in presentation. If we can make modifications to specific therapies, my hope is that this may improve outcomes for autistic service-users recovery.

For my long-scale research project, I am looking to speak to healthcare professionals who have experience of delivering CBT-E and/or MANTRA to autistic service-users. I am interested in hearing about your experiences and expert knowledge. Email me at settersc@cardiff.ac.uk or find me on twitter @setters_chloe for more information.

Chloe Setters

References

Babb, C., Brede, J., Jones, C. R. G., Elliott, M., Zanker, C., Tchanturia, K., Serpell, L., Mandy, W., & Fox, J. R. E. (2021). ‘It’s not that they don’t want to access the support . . . it’s the impact of the autism’: The experience of eating disorder services from the perspective of autistic women, parents and healthcare professionals. Autism, 25(5), 1409-1421. https://doi.org/10.1177/1362361321991257

Bemmer, E. R., Boulton, K. A., Thomas, E. E., Larke, B., Lah, S., Hickie, I. B., & Guastella, A. J. (2021). Modified CBT for social anxiety and social functioning in young adults with autism spectrum disorder. Molecular Autism, 12(11). https://doi.org/10.1186/s13229-021-00418-w

Brede, J., Babb, C., Jones, C., Elliott, M., Zanker, C., Tchanturia, K., Serpell, L., Fox, J., & Mandy, W. (2020). ‘For me, the anorexia is just a symptom, and the cause is the autism’: Investigating restric- tive eating disorders in autistic women. Journal of Autism and Developmental Disorders, 50, 4280–4296. https://doi.org/10.1007/s10803-020-04479-3

Dattaro, L., 2021. Anorexia’s link to autism, explained | Spectrum | Autism Research News. [online] Spectrum | Autism Research News. Available at: https://www.spectrumnews.org/news/anorexias-link-to-autism-explained/ [Accessed 2 December 2022].

Nielsen, S., Anckarsäter, H., Gillberg, C., Gillberg, C., Rastam, M., & Wentz., E. (2015). Effects of autism spectrum disorders on outcome in teenage-onset anorexia nervosa evaluated by the Morgan-Russell outcome assessment schedule: a controlled community-based study. Molecular Autism, 6(14). https://doi.org/10.1186/s13229-015-0013-4

Tchanturia, K., Smith, K., Glennon, D., & Burhouse, A. (2020). Towards and Improved Understanding of the Anorexia Nervosa and Autism Spectrum Comorbidity: PEACE Pathway Implementation. Frontiers in Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.00640