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Eating disorders and autism

Home ~ Eating disorders A-Z ~ Eating disorders and autism

This page outlines the link between autism and eating disorders. It specifically looks at autism and anorexia nervosa, and autism and ARFID.

What is autism?

Autism is a neurodevelopmental condition that affects the way individuals interact and communicate with others.

Autistic people may experience a “spectrum” of symptoms as can be seen in the below diagram. Around one in 100 Australians is diagnosed with autism – around three times as many assigned male at birth (AMAB) as assigned female at birth (AFAB) (Amaze, 2021). Prevalence in the community is likely much higher due to inaccessibility and limitations around diagnosis.  

Autism, food and eating

It is common for autistic people to have atypical eating behaviours, with around 70% of autistic children having issues with food or eating (Mayes & Zickgraf, 2019). 

Autistic individuals may have highly selective eating requirements or be particularly sensitive to the textures, look, smell or sound of foods. The social aspects of eating (such as sitting at a table with others, waiting until others are finished) can also be challenging. There may also be physical difficulties such as oral problems (difficulties chewing or swallowing) or gastrointestinal problems, which make eating a non-pleasurable experience. 

Many of these symptoms and behaviours are commonly seen in people with eating disorders so researchers have sought to further understand the relationship and prevalence of autism in people with eating disorders (and vice versa) – especially in AFAB who experience a higher rate of eating disorders and in whom autism may be under-diagnosed 

All types of eating disorders are experienced by autistic people, the most common are anorexia nervosa (including atypical anorexia) and ARFIDwhich will be explained in more detail below.  

Autism and anorexia nervosa

In the early 1980s a researcher named Christopher Gillberg first identified a possible link between anorexia nervosa and autism due to observed similarities between the two disorders. It was noticed that girls with anorexia and/or autism displayed greater inflexibility, social difficultieslower empathy and a greater tendency to systemise (create and follow rules) than other people. Other similarities observed in those with autism and/or anorexia is a strong interest in details and systems, a tendency to focus on themselves and inflexible behaviours and attitudes. 

It appears that up to 20-35% of women with anorexia meet the diagnostic criteria for autism, with many others exhibiting higher levels of symptoms characteristic of autism than the general population without actually meeting the threshold for a diagnosis (Brede et.al., 2020, Westwood & Tchanturia, 2017) 

Studies have also found that there may be a genetic or familial link between anorexia nervosa and autism and that the conditions have neurobiological links (Koch et.al., 2015). 

It may be that body image is less of a concern for autistic people with anorexia but more so diet restriction as a coping mechanism to mask emotions and anxiety (Brede et.al., 2020). There may also be a tendency for repetitive behaviours taking form of an intense interest (such as calorie counting or exercise) which develops into anorexia (Westwood & Tchanturia, 2017)Autistic people who restrict or avoid foods without a focus on weight or body image may be diagnosed with avoidant/restrictive food intake disorder (ARFID).  

“I misinterpret [emotions] as physical symptoms and I get very anxious about it: Am I unwell? Am I going to vomit? And that’s when I stop eating because I know that will dampen things down and calm them, so my emotions are feeding into my eating disorder behaviours, whereas I think my difficulties in perhaps coping with emotions stem perhaps more from the autism.” (Brede et.al., 2020)

Autism and avoidant/restrictive food intake disorder (ARFID)

Avoidant/restrictive food intake disorder (ARFID) is defined by the DSM-5 as an eating or feeding disorder characterised by a persistent and disturbed pattern of feeding or eating that leads to a failure to meet nutritional/energy needs.

ARFID is similar to anorexia nervosa in that a person restricts their food intake but the intent or reason behind the restriction is different in that people with ARFID do not restrict food in order to avoid weight gain/control their body shape/size. People who are autistic who are underweight or struggle to meet nutritional needs from food may meet the diagnostic criteria for ARFID.

ARFID is a fairly recent DSM-5 diagnostic category and specific research is limited. The prevalence rates of ARFID are currently unknown (estimates range from 5-60% of children being treated as an inpatient for an eating disorder) (Mayes & Zickgraf, 2019). ARFID is more commonly seen in children and adolescents but can occur in adults. There is no specific data on how many people with ARFID also have autism though there appears to be a strong correlation (Mayes & Zickgraf, 2019).

Things to keep in mind for autistic people with an eating disorder

Sensory

Autistic people may have unusual reactions to what they see, hear, smell, touch or taste. This means they often have heightened sensory issues regarding the textures, look, smell and sound of foods than those with no autism.

Routines, rituals and resistance to change

Autistic people may display repetitive behaviours, have a preference for routines and dislike change.  For example, routines and rituals around food such as eating times, places and types of food can be more inflexible and resistant to changes.

Interoception

Interoception is a problem recognising and responding to internal body states and sensations. This can be a problem for autistic people meaning that they may have trouble recognising when hungry or full.

Alexithymia

Alexithymia is having difficulty identifying and describing emotions and is common in autism. People with alexithymia may have a hard time pinpointing what emotion they are feeling and also not be able to communicate what they are feeling to others. This can make it hard for people to soothe themselves or get support from others and can make them more vulnerable to developing eating disorder symptoms as a coping mechanism (Vuillier et.al, 2020).

“I’m not very good at judging my own emotions or physical sensations. I don’t really fully understand my thirst and hunger responses, or my fullness responses, so that really influences my eating because I can binge or miss meals very, very easily.” (Brede et.al., 2020)

Undernourishment and autistic symptoms

It should be noted that undernourishment due to anorexia or ARFID can exacerbate experiences for autistic people (including social difficulties, problems with processing emotions etc.which can make it harder to accurately identify both autism and the eating disorder, due to the uncertainty as to the cause of the symptom. These behaviours may often resolve or improve significantly during recovery. Though there is a link, not all people with anorexia or AFRFID also have autism so it is important to consult professionals who can use a range of criteria for diagnosis of autism and can recommend specific treatment protocols. 

Autism as a consideration in the prevention of eating disorders

As our understanding of autism and eating disorders grows (and evidence that autistic traits appear in early childhood prior to the eating disorder (Solmi et.al., 2020)) there is opportunity for prevention. Treating disordered eating in autistic people early and support and education in proper nutrition despite selective eating or sensory issues, can help prevent the occurrence of eating disorders in the future.  

Treatment and recovery for autistic people with eating disorders

Overall, the recovery prospects and outlook are not any different to neuro-typical people but longer and more intensive treatment may be required(Tchanturia et.al., 2019, Stewart et.al., 2017). Research into the most effective eating disorder treatments for people with autism is still limited and there is a lack of specialist clinicians. We do know that identifying the presence of autism can make treatment and recovery of the eating disorder more effective.  Autistic people experiencing eating disorders may need access to a treatment plan that is not only aware of their autism, but actively understands it and allows treatment to be responsive to the needs of the individual.  

Understanding autism and other neurodiverse conditions (for example learning disabilities, ADHD etc.) as not being an impairment, but instead a functioning difference in the brain is crucial. This is especially important when supporting autistic people with eating disorders, as treatments for the eating disorder should be able to change depending on the needs of the individual.  

Standard eating disorder treatments tend not to accommodate the specific needs of autistic people. They may focus too heavily on weight or body image, involve overwhelming group settings, inpatient stays that disrupt routines and the need for in person visits to medical clinics that may be brightly lit, noisy and unfamiliar. Treatments that require a person to make dramatic changes to their eating routines in a short period of time may also be ineffective for people with autism who simply require more time and a more gradual process of change.  Autistic people may require less food choices and more clarification around rules and expectations in recovery.  

What's next?

There is research currently being conducted in this area and hopefully in time more evidence-based treatment protocols will become available. It is worthwhile noting that formal diagnosis of both conditions are relatively rare (1% of the population with autism and less than 1% with anorexia nervosa/ ARFIDso despite there being a clear relationship, the development of evidence can be slow. Also, due to the stigmatisation of both autism and eating disorders, getting an in depth understanding of their connection and how to support people with them, is slower than what is ideal.  

Learn more

Further reading

Other support options

Amaze website and free national autism helpline 1300 308 699 providing information, advice and referrals to help autistic people, their supporters and professionals. 

Eating Disorders Families Australia (EDFA) offers an ARFID support group. More information can be found here.  

Peace (Pathways for Eating Disorders and Autism developed from Clinical Experience) website has a great deal of information and resources for people with autism and eating disorders and their carers and clinicians.  

References

Brede, J., Babb, C., Jones, C. et al. (2020). For Me, the Anorexia is Just a Symptom, and the Cause is the Autism: Investigating Restrictive Eating Disorders in Autistic Women. J Autism Dev Disord 50, 4280–4296.

Gillberg C (1983) Are autism and Anorexia Nervosa related? British Journal of Psychiatry 142: 428.

Kinnaird, E., Norton, C. & Tchanturia, K. (2017). Clinicians’ views on working with anorexia nervosa and autism spectrum disorder comorbidity: a qualitative study. BMC Psychiatry 17, 292.

Koch SV, Larsen JT, Mouridsen SE, Bentz M, Petersen L, Bulik C, Mortensen PB, Plessen KJ. (2015). Autism spectrum disorder in individuals with anorexia nervosa and in their first- and second-degree relatives: Danish nationwide register-based cohort-study. Br J Psychiatry. 206 (5):401-7.

Mayes, SD, & Zickgraf, H. (2019). Atypical eating behaviors in children and adolescents with autism, ADHD, other disorders, and typical development. Research in Autism Spectrum Disorders, 64, 76-83.

Solmi, F F, Bentivegna, HB, William M, Radha K, Dheeraj R, David S, Glyn L. (2020). Trajectories of autistic social traits in childhood and adolescence and disordered eating behaviours at age 14 years: A UK general population cohort study. Journal of Child Psychology and Psychiatry,

Stewart CS, McEwen FS, Konstantellou A, et al. (2017) Impact of ASD Traits on treatment outcomes of eating disorders in girls. European Eating Disorders Review 25: 123–128

Tchanturia K, Larsson E and Adamson J (2016) How anorexia nervosa patients with high and low autistic traits respond to group Cognitive Remediation Therapy. BMC Psychiatry 16: 334.

Tchanturia, K, Adamson, J, Leppanen, J, & Westwood, H. (2019). Characteristics of autism spectrum disorder in anorexia nervosa: A naturalistic study in an inpatient treatment programme. Autism : The International Journal of Research and Practice, 23(1), 123-130.

Vuillier, L., Carter, Z., Teixeira, A.R. (2020). Alexithymia may explain the relationship between autistic traits and eating disorder psychopathology. Molecular Autism 11, 63

Westwood H, Mandy W and Tchanturia K (2017) Clinical evaluation of autistic symptoms in women with Anorexia Nervosa. Molecular Autism 16: 812.

Westwood, H., & Tchanturia, K. (2017). Autism spectrum disorder in anorexia nervosa: An updated literature review. Current Psychiatry Reports, 19(7), 41.

Need help?

Eating Disorders Victoria has put together a step-by-step guide take if you are concerned that you may be experiencing an eating disorder. It also covers how to talk to family or friends about what you’re going through. Remember that you have the best chance of success if you include people you trust on your journey.

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