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April 13, 2017

Are Anorexia and Autism Related?  – Dr. Ralph Carson

are anorexia and autism connectedMany people understand that people with autism spectrum disorders (ASD) display abnormal eating habits, which may include refusing foods with smells, tastes and textures that are perceived to be disagreeable to their senses.
 
Certain eating disorder professionals may be surprised to learn that there is a fairly significant percentage of anorectic patients that also have autism-like symptoms.
 
Does this mean that a large number of people struggling with anorexia also have an autism spectrum disorder? Absolutely not. In fact, a rather small percent of people with anorexia exhibit autism-type behaviors. These disorders are extremely complex and complicated but we do see traits and eating behaviors that parallel each other. Here are just a few examples:
 
  • Picky eating behavior
  • Limited food choices
  • A tendency to resist novelty
  • Rituals and perfectionism
  • Rigid attitudes and ways of thinking & poor set shifting
  • Inflexible behaviors
  • Poor central coherence
  • Propensity for very low body weight
 
Research is continuously providing new insights into the causes and symptoms of both anorexia and ASD and much progress is being made regarding treatment and-long term recovery. Therapists and healthcare professionals should strive to remain updated on this topic and take the following into consideration when working with patients.
 
What is anorexia?
 
Anorexia is characterized by an obsessive fear of gaining weight, a refusal to maintain a healthy body weight and (often) a struggle with body image. People with anorexia may restrict their food intake and/or compulsively exercise. Importantly, anorexia is the deadliest mental illness, with a higher mortality (death) rate than any other mental illness.
 
Weight restoration is an essential goal of anorexia treatment that best predicts successful outcomes. However, even after weight is fully restored, some individuals still struggle with behaviors that resemble autism-like behavior (social impairment, difficulty forming relationships, repetitive behaviors and the inability and unwillingness to change set routines).

What is autism spectrum disorder?
 
Autism spectrum disorder includes three primary categories of symptoms:
 
1) Social impairment
2) Communication impairment (a delay in speech development)
3) Repetitive behaviors.
 
Some examples of behaviors observed in those with ASD include:
 
  • Poor use of non-verbal gestures (facial expressions, eye contact)
  • Not engaging in age-appropriate social play and interactions
  • Mood instability (impulsivity, inattention, aggression)
  • Preoccupation with one or more interests or objects
  • Routine-oriented, inflexible
  • Hyperactive, may repeat mannerisms
 
These symptoms affect social relationships and they affect learning.
 
People with ASD that consume a limited variety of foods due to sensory issues may be diagnosed with disordered eating. But, even though the individual has a very low body weight, they may not be diagnosed with anorexia because the eating disorder is not stemming from a drive for thinness or a fear of becoming fat.
 
The overlap between anorexia and autism
 
Studies show that relatives of those with anorexia have a higher incidence of autism spectrum disorders than the average person (Koch ’15). Between five to twenty percent of those with anorexia fall on the autism spectrum (Zucker ‘07;  Mandy ’14; Gillberg ‘85; ‘97; Szalavitz ’14; Wentz ‘05) and more than one in four people with autism demonstrate disordered eating behaviors (Gurtz ‘12).
 
Here are some additional similarities between those with anorexia and those with ASD:
 
  • An obsession with details
  • Self-preoccupation
  • Struggle to relate to peers
  • Struggle to communicate
  • Rigidity and inflexibility
  • Alexithymia (trouble reflecting on one’s own emotions)
  • Eating issues; limited food choices
  • OCD tendencies – repetitive thoughts/behaviors, checking
  • Perfectionism and ritualistic tendencies
  • Compulsive exercising and frequent fidgeting
  • Resistance to change
  • Trouble regulating emotions
  • Low empathy for others
  • Resistance to novelty
     
How can we best help patients and families?
 
If autism is suspected in an individual with anorexia, it should be assessed by a professional. Then, the following treatment options, along with medications and counseling, can be considered:
 
  • Neurofeedback 
  • Family therapy – How do the parents communicate with the child? Families can work on improving communication, emotional identification and expression, and body language (i.e. when parent is calm, the child, too, tends to be calmer)
  • Exposure and response prevention (ERP) – Helpful for minimizing anxiety and fears
  • Cognitive remediation – Helpful for increasing flexibility, planning and problem solving
  • Nutritional therapy – Group meals and processing (i.e. distractions from rituals and ruminating about weight gain) can best be carried out in an intensive group setting
  • Expressive therapy – Examples include art therapy, equine therapy and movement therapy; may help develop appropriate communication skills
  • Acceptance and commitment therapy (ACT) – Helps to identify one’s personal values consistent with achieving one’s goals and purpose; teaches us to accept our differences and honor our unique qualities
  • Oxytocin – Reported outcomes thus far are mixed, but those with ASD are considered to be oxytocin-deficient (Kirsch ‘05; Dalton ‘05); one study found that oxytocin helped improve attitudes towards food and social relationships (reduced eating vigilance and reduced feelings of low self-worth) (Kim ’14, 15b; Ramono ’15; Szalavitz ‘14); this is currently an experimental intervention best administered as a nasal inhalant
     
Experts are seeing a number of similar symptoms between women who have anorexia and women with autism spectrum disorders. In treatment, we acknowledge that those with autism and anorexia may continue to make different decisions in their eating habits and food choices. But even with a genetic predisposition to these disorders, we can learn to exist and be present in the world; we can learn how to eat enough to live.
 
Ralph Carson, RD, PhD, is a nutritionist and exercise physiologist with over 40 years of experience. He is currently Vice President of Science and Innovation for Eating Recovery Centers (ERC) and the Binge Eating Treatment and Recovery Program (BETR) in Chicago and other locations. BETR focuses on loss of control and binge eating. Dr. Carson is an active member on the board of the International Association of Eating Disorder Professionals (iaedp) and author of The Brain Fix: What’s the Matter with Your Gray Matter.
 
April is National Autism Awareness Month, reminding us to be aware of the unique challenges faced by those with autism.

References:

Koch SV et al 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 (2015) 206: 401 -407 

Gillberg C Are autism and anorexia nervosa related? Br J Psychiatr (1983) 142: 428

Gillberg C and Rastam M Do some cases of anorexia nervosa reflect underlying autistic-like conditions? Behav Neurol (1992) 5: 27 – 32

Mandy W and Tchanturia K Do women with eating disorders who have social and flexibility difficulties really have autism? A case series Mol Autism (2015) 13: 6

Szalavitz M A Genetic Link between Anorexia and Autism? Time Magazine (June 19, 2009)

Wentz E et la Childhood onset neuropsychiatric disorders in adult eating disorder patients. A pilot study Eur Child Adolesc Psychiatry (2005) 14: 431 – 437

Zucker N et al : Anorexia nervosa and autism spectrum disorders: guided investigation of social cognitive endophenotypes. Psychol Bull. (2007) 133: 976-1006

Dalton KM et al Gaze fixation and the neural circuitry of face processing in autism Nat Neurosci (2005) 8: 519 – 26
Kirsch P et al Oxytocin modulates neural circuitry for social cognition and fear in humans J Neurosci (2005) 25: 11489 - 93

Kim YR et al Differential methylation of the oxytocin receptor gene in patients with anorexia nervosa: a pilot study PLos One (2014) 9:e88673

Kim YR et al The Impact of Oxytocin on Food Intake and Emotion Recognition in Patients with Eating Disorders: A Double Blind Single Dose Within-Subject Cross-Over Design PLoS One (2015) 10: e0137514 

Kim YR et al The impact of intranasal oxytocin on attention to social emotional stimuli in patients with anorexia nervosa: a double blind within-subject cross-over experiment PLoS One (2015) 9: e90721

Romano A et al From Autism to Eating Disorders and More: The Role of Oxytocin in Neuropsychiatric Disorders Front Neurosi (2015) 9: 497

Szalavitz M A Genetic Link between Anorexia and Autism? Time Magazine (June 19, 2009)
 
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