The autism diagnostic observation schedule: Patterns in individuals with anorexia nervosa

Social communication and restricted, repetitive behavior as assessed with a diagnostic tool for autism (ADOS-2) in women with anorexia nervosa

OBJECTIVE

In anorexia nervosa (AN), the traits of autism spectrum disorder (ASD) are associated with poor outcomes. However, the subtle nature of these characteristics remains poorly understood. We investigated the in-depth patterns of ASD traits using Autism Diagnostic Observation Schedule-Second Edition (ADOS-2) in women with AN.

METHODS

Of 28 women with ICD-10 AN, 16 (age 19-30 years) participated in the ADOS-2, a video-recorded, semistructured diagnostic assessment for social communication and interaction and restricted, repetitive behaviors and interests related to ASD. None of the participants had previously been diagnosed with ASD. Other measurements included the Eating Disorder Examination Questionnaire and the Wechsler Abbreviated Scale of Intelligence-IV.

RESULTS

Five individuals (18% of all, 31% of those assessed) scored above the cutoff for autism in ADOS-2. They had challenges in social communication and interaction, manifesting as sustained difficulties in social relationships and deficits in conversation skills. Few described being frequently misunderstood by others, including in the eating disorder treatment settings. Three individuals showed prominent restricted and repetitive behaviors such as ritual seeking, eating-related routines, sensory sensitivity related to food texture and selective eating, and intense interest in specific topics. The mean duration of AN in women above the cutoff was twice as long compared with those below (12.3 vs. 6.2 years).

DISCUSSION

The ASD-related characteristics and behavior appear to contribute to the manifestation and duration of AN in a subgroup of women. Among these women, the traits of ASD appear to be mixed with eating disorder symptoms, which should be taken into account in the treatment.

Analysis of symptom clusters amongst adults with anorexia nervosa: Key severity indicators

This study used cluster analysis to explore clinically relevant subgroups of adult patients with anorexia nervosa (AN). Patients were clustered based on their body mass index (BMI), eating disorder symptomatology, anxiety and depression symptoms and autistic characteristics. The difference between clusters in work and social functioning, duration of illness, bingeing and purging behaviour, previous hospitalisations and number of comorbidities was also investigated. Two meaningful clusters emerged: a higher symptoms cluster with more severe eating pathology, anxiety, depression, and more autistic traits, and a second cluster with lower symptoms. BMI did not make major contributions to cluster formation. The higher symptoms cluster also reported lower self-efficacy to change, more previous hospitalisations, comorbid diagnoses, binge eating and purging behaviours and use of psychotropic medication. Our findings suggest that weight alone may not be a significant severity indicator amongst inpatients with AN, and targeted treatment of AN should consider a broader range of symptom severity indicators.

Autism diagnosis in females by eating disorder professionals

IMPORTANCE

Autism and eating disorders cooccur at high rates, with autism impacting the efficacy of eating disorder treatments and outcomes. Females are underdiagnosed with autism and diagnosed later in life than their male counterparts.

OBJECTIVE

The purpose of this study was to define the incidence of eating disorder professionals identifying autism in female adolescents and young adults engaged in treatment for an eating disorder.

DESIGN

The research design is a cross-sectional retrospective records review. The charts reviewed were from the medical records of forty assigned-at-birth females between the ages of 13-25 who received treatment for an eating disorder at the partial hospitalization program (PHP) level of care between 2020 and 2022.

MAIN OUTCOMES

Upon entering PHP for an eating disorder, 10% of the study participants had a pre-existing diagnosis of autism. A total of 27.5% of participants had clinical suspicion of autism. The number of autism traits that an individual possessed directly correlated with the number of calendar days in treatment.

CONCLUSION

Eating disorder professionals in this study identified autism in 17.5% of adolescent and young adult females who entered PHP treatment for an eating disorder who had not previously been diagnosed with autism. Eating disorder professionals can anticipate that individuals with autism may be in treatment for a longer duration. Further studies should explore effective treatment measures for those with autism in treatment for an eating disorder.

The obsessive-compulsive spectrum: A network analysis

Several studies have shown that obsessive-compulsive disorder (OCD), eating disorders (ED), autism spectrum disorders (ASD) and body dysmorphic disorder (BDD) share obsessive-compulsive (OC) symptoms and often co-occur, which could be seen as indicative of a common etiological basis. In addition, they also appear to have similarities in executive functioning. The present study investigated disorder-specific symptoms and executive functioning as a possible joint factor in individuals with OCD (n=53), BDD (n=95), ED (n=171) and ASD (n=73), and in healthy controls (n=110). The participants completed online questionnaires measuring OCD, ED, ASD and BDD related symptoms as well as executive functioning. The clinical groups were first compared to the healthy controls. Subsequently, a network analysis was performed only with the OC-groups. This network approach assumes that psychopathological disorders are the result of causal symptom interactions. As expected, the healthy controls reported less severe symptoms compared to the OC patient groups. The network analysis suggested that the executive functioning skill set shifting/attention switching and the ASD symptoms, social and communication skills were the most central nodes in the model. Difficulty with cognitive flexibility and social factors are central in OC-spectrum disorders and may be perpetuating factors and thus a relevant focus of treatment.

The Diagnosis and Management of Autism Spectrum Disorder (ASD) in Adult Females in the Presence or Absence of an Intellectual Disability

We review the reasons for the greater male predominance in the diagnosis of autism spectrum disorder in the non-intellectual disabled population and compare it to autism diagnosed in intellectually disabled individuals. Accurate and timely diagnosis is important, as it reduces health inequalities. Females often present later for the diagnosis. The differences are in core features, such as in social reciprocal interaction through 'camouflaging' and restricted repetitive behaviours, that are less noticeable in females and are potentially explained by the biological differences (female protective effect theory) and/or differences in presentation between the two sexes (female autism phenotype theory). Females more often present with internalising co-occurring conditions than males. We review these theories, highlighting the key differences and the impact of a diagnosis on females. We review methods to potentially improve diagnosis in females along with current and future management strategies.

Anorexia nervosa and comorbid autism spectrum disorders

PURPOSE OF REVIEW

Traits of autism spectrum disorder (ASD) are overrepresented among individuals with anorexia nervosa (AN) and may also moderate the behavioral manifestation of AN. This review aims to provide an overview of AN and comorbid ASD.

RECENT FINDINGS

Elevated ASD traits do not seem to precede AN among some individuals but are rather related to the illness stage. However, studies have suggested that there are ASD-specific mechanisms for developing AN in a subgroup of individuals with AN. Pronounced traits of ASD and diagnosed ASD are associated with illness prolongation and poorer outcomes in AN, and individuals with AN and elevated ASD traits may benefit less from many of the current treatments. Studies do not support a specific genetic relationship between ASD and AN.

SUMMARY

Recent research encourages the improved recognition of elevated ASD traits in individuals with AN and provides grounds for developing tailored treatments for those with this comorbidity.

Autism symptoms in anorexia nervosa: a comparative study with females with autism spectrum disorder

Background

Recent research suggests a link between autism spectrum disorder (ASD) and anorexia nervosa (AN). Individuals with AN show high scores on measures of ASD symptoms, relative to individuals without AN, however, there are currently no studies directly comparing women with AN to women with ASD. The aim of the current study was to examine profiles of ASD symptoms in young women in the acute and recovered stages of AN, women with ASD, and typically developing controls (TD), on both self-report and clinical interview measures.

Methods

Four groups of participants aged 12–30 years were included (n = 218): AN, recovered AN (REC), ASD, and TD. Group differences on the Social Responsiveness Scale, 2nd edition (SRS-2), 10-item Autism Quotient (AQ-10), and the Autism Diagnostic Observation Schedule, 2nd edition (ADOS-2) were examined. To explore similarities and differences in specific symptom profiles associated with AN and ASD, individual item endorsement on the ADOS-2 was also examined in AN, REC, and ASD.

Results

Across measures, women with ASD showed the highest scores, and TDs the lowest. Generally, individuals with AN and REC showed intermediate levels of ASD symptoms, scoring between the other two groups. However, AN and ASD did not differ on restricted interests and repetitive behaviour subscales. The ADOS-2 item ‘quality of social response’ adequately discriminated between ASD and non-ASD participants.

Limitations

A full diagnostic assessment for ASD was not provided for participants with AN/REC, nor were eating disorders assessed in the ASD group. Therefore, some diagnostic overlap between groups is possible. The cross-sectional design is another limitation.

Conclusions

The results suggest similarities in scores on both self-report and clinical interview measures in AN and ASD. However, individual ADOS-2 item analyses also revealed subtle differences, particularly in reciprocal social interaction. ASD symptoms may be a combination of both state and trait features in AN.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13229-021-00455-5.