Clinicians' views on working with anorexia nervosa and autism spectrum disorder comorbidity: a qualitative study

Camouflaging, not sensory processing or autistic identity, predicts eating disorder symptoms in autistic adults

LAY ABSTRACT

This study aimed to explore the impact of Autistic identity (i.e. feeling like you belong to the Autistic community), sensory profiles (e.g. being over or under responsive to sensations) and camouflaging behaviours (i.e. masking) on eating disorder symptoms in Autistic adults. 180 Autistic people were recruited from the community and NHS. The Autistic people completed online questionnaires measuring Autistic identity, sensory profiles, camouflaging behaviours, autistic traits and eating disorder symptoms. The analysis showed that higher levels of camouflaging behaviour predicted higher levels of eating disorder symptoms. Sensory profiles were related to but did not predict eating disorder symptoms and there was no relationship between level of Autistic identity and eating disorder symptoms. This shows that camouflaging is the most important predictor of eating disorder symptoms in Autistic people, and warrants further exploration.

"Don't talk to me like I am an illness": exploring patients' needs using the communication passport in an eating disorder service

PURPOSE

Social challenges are common in patients with eating disorders (ED). The presence of autistic characteristics often exacerbates social difficulties within this group, potentially affecting treatment outcomes. This study investigates the communication preferences, challenges, dislikes, and support needs of patients with ED, both with and without autistic traits, using a communication passport in a national inpatient ED service.

METHODS

An explorative qualitative analysis of 38 completed communication passports was conducted to investigate patients' communication preferences, sensory needs, struggles and dislikes, and areas of support required, paying particular attention to the distinct needs of patients with high levels of autistic traits.

RESULTS

The communication passport provided valuable insights into patients' communication preferences, sensory sensitivities, challenges, and support needed. Patients also used the passports to share information about their strengths, personal identity, and life beyond the hospital.

CONCLUSION

The communication passport fosters a deeper understanding of patients' needs and may support clinicians in care planning and communication strategies tailored to each patient's needs. Regular evaluation and updates are warranted to ensure its usability and accessibility by the wider care team.

Mental Health Professionals' Experiences of Adapting Mental Health Interventions for Autistic Adults: A Systematic Review and Thematic Synthesis

Autistic adults experience high rates of metal health difficulties and face significant barriers to accessing appropriate mental health care. Empirical research and recent professional guidelines emphasise the importance of modifying standard mental health interventions to best meet the needs of autistic adults. This systematic review explored mental health professionals' experiences of adapting mental health interventions for autistic adults. A systematic search was conducted on CINAHL, PsychINFO, PubMed, Scopus, and Web of Science in July 2022. The findings from 13 identified studies were synthesised using thematic synthesis. Three major analytical themes were generated, the unique experience of adapting interventions for autistic clients, factors which facilitate successful adaptations, and challenges to adapting interventions. Each theme contained a number of subsequent sub-themes. Professionals view the process of adapting interventions to be a highly individualised process. A range of personal traits, professional experiences, and systemic, service-based issues were identified in facilitating or challenging this individualised process. Further research regarding adaptations with different intervention models and increased supportive resources are required to enable professionals to successfully adapt interventions for autistic adult clients.

A qualitative evaluation of the pathway for eating disorders and autism developed from clinical experience (PEACE): clinicians' perspective

Introduction

The Pathway for Eating disorders and Autism developed from Clinical Experience (PEACE pathway) is a clinical pathway of adapted treatment for individuals with eating disorders and autism in the UK. This study aims to investigate multidisciplinary clinicians' views of the strengths and challenges of PEACE pathway adaptations, while identifying areas where further improvement is needed.

Method

Semi-structured interviews were conducted with 16 clinicians who worked on the PEACE pathway. Themes relevant to the benefits, challenges and areas of improvement were identified, and a thematic map was produced.

Results

PEACE Pathway brought clinical benefits such as improved understanding of patients' perspective, improved flexibility and individualisation in clinicians' approach, increased patient engagement, and provision of resources that are helpful to all patients with or without autism. Benefits to the service included increase in autism awareness, clinicians' confidence, and team collaboration. Challenges were also identified, including difficulties in incorporating autism adaptations into existing treatment protocol, implementing PEACE at different levels of care, staff schedule conflicts, and increased pressure to meet patients' needs. Overall, there is a need for systemic improvement in aftercare and community support for autism, more suitable autism screening tool, and more structured guidelines for making adaptations.

Conclusions and implications

PEACE Pathway has brought clinical and service benefits, while also bringing practical challenges rooted in the difficulty in distinguishing between autism and eating disorder in comorbid population. Future areas of improvement are highlighted for PEACE resources as well as in the national support system for autistic individuals.

Exploring the intersection of autism spectrum disorder and eating disorders: understanding the unique challenges and treatment considerations for autistic women with eating disorders

PURPOSE OF REVIEW

Autistic women struggle with high levels of both autistic eating behaviours and disordered eating behaviours , which might make them particularly vulnerable to develop eating disorders. Research investigating the presence and characteristics of eating disorders in autistic women is however limited, as is research examining the role of autism in the treatment and recovery of an eating disorder in autistic women.

RECENT FINDINGS

The link between autism and eating disorders has mainly been investigated from the field of eating disorder research, with studies finding an overrepresentation of autism or autistic traits in eating disorders populations. Findings also suggest that autism or autistic traits are associated with a more serious presentation of the eating disorders, including a higher chance of a chronic course of the eating disorders. Most studies however lack comprehensive autism assessments, making it difficult to determine the actual prevalence of autism and its role in women with eating disorders.

SUMMARY

Autistic women with an eating disorder seem to suffer from more complex eating disorders and seem to not benefit from current treatment modalities. This could be partly related to specific autism characteristics such as sensory sensitivities, which are not being considered by current treatment protocols. Future research needs to shed light on what underlies the eating behaviours of autistic women with an eating disorder, in order to help to adapt current treatment modalities to meet the unique needs of these women.

The Influence of Comorbidity and Perceived Complexity on Outcomes of Referrals to Children and Young Person Mental Health Services (UK): A Mixed Methods Vignette Study

Children and young people (CYP) with long-term physical conditions (LTCs) are four times more likely to develop mental health disorders yet many cannot access Children and Young People's Mental Health Services (CYPMHS) or evidence-based interventions. This study aimed to understand the reasons for this; presence of an LTC neurodevelopmental disorder, or service requirements. 79 CYP mental health practitioners were randomly assigned to read vignettes depicting a hypothetical referral letter for a child with a mental health condition alone (n = 27), mental health condition and LTC (n = 25), or mental health condition and neurodevelopmental disorder (Autism Spectrum Disorder-ASD) (n = 27), answering questions about their likelihood of accepting the referral and proposed treatment plan. There were no significant differences between accessing CYPMHS or being offered first line evidence-based interventions in those with a LTC or ASD compared to those without. However, additional perceived complexity was frequently provided as a reason for rejecting referrals and not offering evidence-based intervention, with clinicians' predicted success of intervention significantly lower for these CYP. Clinicians were significantly more likely to suggest adapting the intervention in the LTC and the ASD groups to account for additional perceived complexity. The research suggests a need for additional services for CYP with LTCs and those with neurodevelopmental disorders, as well as training/awareness for clinicians.

Perceptions of health professionals in providing care for people with anorexia nervosa and bulimia nervosa: a systematic review and meta-synthesis of qualitative studies

This study sought to synthesize and reinterpret findings from primary qualitative studies on the experience of health professionals in caring for people with anorexia nervosa and bulimia nervosa. We conducted a systematic review of the literature with the SPIDER search strategy assessing six databases. A meta-synthesis was performed with data from qualitative studies. Two independent reviewers screened and assessed the articles, extracted data from the articles and elaborated thematic synthesis. Nineteen articles met the inclusion/exclusion criteria. The meta-synthesis revealed three descriptive themes: Going outside the comfort zone: hard relational experiences of health professionals in providing care for people with anorexia nervosa and bulimia nervosa; Reflecting on treatment: relevance of discussion, communication, and flexibility in health professionals' work with anorexia nervosa and bulimia nervosa; and Dealing with ambivalences: experiences of health professionals with family members of people with anorexia nervosa and bulimia nervosa. We elaborated two analytical themes: Making work with eating disorders palatable: malleability necessary for health professionals in bonding with people with anorexia and bulimia nervosa and their families; and Leaving the professional comfort zone: transition from multi to interdisciplinary. Thus, mental health professionals who work with people diagnosed with anorexia and bulimia nervosa cope with hard emotional experiences that makes them feel out of their comfort zone, requiring flexibility to benefit a good therapeutic alliance, but there are still difficulties in promoting interdisciplinarity.

"Work WITH us": a Delphi study about improving eating disorder treatment for autistic women with anorexia nervosa

BACKGROUND

There is an increased prevalence of anorexia nervosa (AN) in autistic women and this group has poorer treatment outcomes compared to non-autistic women with AN. However, there is little research into improving eating disorder treatment for autistic women. This study investigated how best to support autistic women with AN within eating disorder services.

METHOD

A three-stage Delphi study was conducted with 49 participants with relevant expertise as a researcher, clinician, or expert by experience.

RESULTS

A total of 70 statements were generated, with 56 reaching consensus after the final round. Statements reaching consensus made recommendations for adaptations to treatment, staff training, and service organisation.

CONCLUSIONS

The results highlight the need to distinguish between autism- and AN-related difficulties, accommodate autistic traits such as sensory sensitivities and communication differences, and ensure the autistic voice is present in both the development and delivery of care. Future research should investigate the impact of these adaptations on outcomes. The applicability of these recommendations to autistic people with other eating disorders and of other genders needs to be investigated further.

Finding the Proportion of Females with Autistic Spectrum Disorder Who Develop Anorexia Nervosa, the True Prevalence of Female ASD and Its Clinical Significance

It appears that up to 80% of females with autistic spectrum disorder (ASD) have not been diagnosed by the age of 18. This translates to a prevalence of about 5-6%, and if true, has serious implications for female mental health. One way of finding the true value is to use Bayes' Theorem with a comorbid condition as a more easily recognizable flag. An obvious choice is anorexia nervosa (AN), but it transpires that the proportion of women with ASD who develop AN is unknown. This study uses published data in novel ways to provide two methods of estimating a range for this variable, and gives a median value of 8.3% for AN in ASD and, with four other methods, a median prevalence of 6% for female ASD. The clinical implications of the diagnosis and management of ASD and its comorbidities are discussed and, as an example, a solution is provided for the rate of ASD in symptomatic generalized joint hypermobility. It is probable that one in six women with a mental health condition is autistic.

The associations between autistic traits and disordered eating/drive for muscularity are independent of anxiety and depression in females but not males

Previous research has shown a positive correlation between autistic traits and eating disorder symptoms, and this relationship appears to be independent of co-occurring mental health status. The current study followed a pre-registered analysis plan with the aim to investigate a previously unconsidered factor in the relationship between autistic traits and disorders of eating and body image: the drive for muscularity. Participants (N = 1068) completed the Autism Spectrum Quotient (AQ), Hospital Anxiety and Depression Scale (HADS), Eating Attitudes Test-26 (EAT-26) and Drive for Muscularity Scale (DMS). Positive correlations between AQ and EAT-26 and AQ and DMS were observed. In females, AQ remained significantly correlated with EAT-26 and DMS when controlling for co-occurring anxiety and depression symptoms, but this was not the case in males. These findings demonstrate the moderating role of sex, and the need to consider autistic traits in individuals diagnosed with, or at a heightened risk for, disorders of eating and body image.

Different pathways, same goals: A large-scale qualitative study of autistic and non-autistic patient-generated definitions of recovery from an eating disorder

BACKGROUND

Definitions of recovery from an eating disorder (ED) have generally been formulated around clinical conceptualisations, rather than based on the views of patients. This paper therefore asked those with lived experience of ED for their own definitions of recovery.

METHOD

Data were collected as part of an online study looking at EDs, autism and relationships. About 173 participants identified as recovered from ED and gave free-response definitions of recovery. Responses were subject to thematic analysis.

RESULTS

Seven major themes were identified: Weight restoration, lack of ED behaviours, thoughts and behaviours, cognitions, emotional responses, getting on with life, and ongoing challenges.

CONCLUSIONS

Many definitions of recovery given by those who have lived experience of ED echoed those used by clinicians and researchers. There were also points of divergence around the ongoing challenges of recovery. Our findings highlight the need for continuing support post-weight restoration to facilitate the successful long-term recovery for those with ED.

A comparison of the eating disorder service experiences of autistic and non-autistic women in the UK

Objective

Qualitative studies report that autistic women have poor experiences when being treated for an eating disorder (ED) and express that ED services are not appropriately tailored to meet their needs. It is unclear whether their experience differs to other women accessing ED services. The aim of the current study was to compare autistic and non‐autistic women's ED illness history and experiences in ED services.

Method

An online survey about ED illness history and their experience with ED treatment was completed by 46 autistic women with a restrictive ED and 110 non‐autistic women with a restrictive ED.

Results

Despite some similarities, there were three key differences in the experiences reported by autistic and non‐autistic women. First, autistic women reported a longer duration of ED and being diagnosed with an ED at a younger age than non‐autistic women. Second, autistic women reported accessing a broader range of healthcare settings and ED treatments than non‐autistic women when being treated for an ED. Finally, autistic women rated their experiences of inpatient care, dietetic input, and cognitive behavioural therapy (CBT) as significantly less beneficial than non‐autistic women when being treated for an ED.

Conclusion

These findings increase understanding of autistic women's ED experience and can help to shape ED services and treatments to better accommodate the needs of their autistic clients.

The current study is the first to compare the eating disorder (ED) illness history and treatment experiences of autistic and non‐autistic women.

Autistic women with EDs are diagnosed at a younger age and report longer illness duration than non‐autistic women.

Autistic women with EDs tend to access a broader range of healthcare settings and ED treatments than non‐autistic women, but report these to be less beneficial.

Beyond what clinicians see: missed diagnosis and misdiagnosis of a woman with autism spectrum disorder

A young woman with autism spectrum disorder was admitted to the hospital via the emergency care unit. On being admitted, she was improperly diagnosed with a psychotic disorder due to her erratic behaviour and incomprehensible refusal to eat. As a result, the patient was hospitalised against her will. For accurate and correct diagnosis and treatment, it was necessary to collect the patient's detailed clinical history, while being hospitalised.

Autism and anorexia nervosa: Longitudinal prediction of eating disorder outcomes

BACKGROUND

Recently, elevated levels of autistic features and autism diagnoses have been reported among people with anorexia nervosa (AN). In clinical settings high levels of autistic features have been linked to more complex, highly comorbid illness presentation and poorer treatment outcome. This study aimed to examine whether autistic features predict AN symptom profile in long term.

METHODS

Altogether 118 women with lived experience of AN completed two autism assessments at time 1, the Autism Diagnostic Observation Schedule (ADOS) and the short version of the Autism Quotient (AQ10). Measures assessing AN symptom profile, including eating disorders symptoms, anxiety, depression, OCD symptoms, and Body Mass Index (BMI), were also recorded. The symptom profile measures were administered again 6 months and 2 years later. We conducted two analyses to examine the extent to which the ADOS and AQ10 scores predicted broad AN symptom profile at each three time points.

RESULTS

Overall, high levels of autistic features were consistently associated with worse psychological symptoms, but not BMI, across all time points. Both the analysis using baseline ADOS scores and self-reported AQ10 scores showed similar pattern.

CONCLUSION

The present findings consolidate previously reported associations between autistic features and worse psychological outcome among people with AN. The findings also suggest that self-report measures may be sufficient for assessing the impact of autistic features on illness outcome among people with AN. Importantly, the study highlights the need for development and further investigation of neurodiversity accommodations in the treatment of AN.

Widening the reach of family-based interventions for Anorexia Nervosa: autism-adaptations for children and adolescents

Family-based interventions are widely recommended as a first line treatment for children and young people with Anorexia Nervosa. There is clear evidence that model-adherent delivery of specific eating disorder focused family interventions has the potential to help adolescents with Anorexia Nervosa, who have typically engaged in extreme dietary restriction and lost a significant amount of weight over a relatively short period of time. Nevertheless, there remains a significant number of young people with restrictive eating disorders for whom family-based interventions for Anorexia Nervosa prove less effective, suggesting adaptations may be indicated for some. In this paper we provide a rationale and structure for considering a number of possible adaptations to the delivery of family-based therapy for anorexia nervosa specifically intended to enhance its relevance and potential effectiveness for children and adolescents on the autism spectrum; a subgroup known to represent a significant minority in eating disorder populations who have been identified as having relatively poor outcomes. Past research has shown that certain family-based treatments are effective for many children and adolescents who develop Anorexia Nervosa. At the same time this type of treatment approach in its current form does not work for everyone. Recent research has highlighted the overlap between anorexia and autism and the need for the development of adaptations to existing treatments to better meet the requirements of people on the autism spectrum who develop anorexia. With this in mind we propose a number of autism-related adaptations that could be made to family-based treatments for anorexia. We hope that these might be formally tested in the future to see if these adaptations improve outcomes for this group of individuals.

Anorexia Nervosa and Autism Spectrum Disorder: A Systematic Review

BACKGROUND

Recent research has shown a growing interest in exploring the relationship between anorexia nervosa (AN) and autism spectrum disorder (ASD). Both conditions seem to share areas of cognitive, social and behavioural impairment, leading to relevant implications on treatment, especially when they are in comorbidity. This literature review aims to synthesise the latest studies on this topic to investigate the co-occurrence of AN and ASD, suggest future research directions and consider implications for treatment.

METHOD

Records were systematically (PRISMA guidelines) identified through PubMed, EBSCOhost, Scopus and Web of Science searching.

RESULTS

Thirteen studies met the eligibility criteria and were therefore included in the review. Results seem to confirm an overrepresentation of ASD symptoms in AN. Only few studies investigated the AN-ASD comorbidity in young people and report slightly lower rates than those conducted with adults.

CONCLUSIONS

Analysed studies suggest that while the comorbidity seems to exacerbate the severity of the condition, autistic traits appear to be rather stable over time and not related to body weight. Thus, future longitudinal studies and gender- specific assessment tools can help clarify the relationship between the two disorders, examine the onset of ASD symptoms and develop structured guidelines for treatment.

Autistic characteristics in eating disorders: Treatment adaptations and impact on clinical outcomes

OBJECTIVE

Autistic people with eating disorders (EDs) may have special needs that are not met in standard ED treatment, raising the need for treatment adaptations to accommodate co-existing autism spectrum condition (ASC). Little is currently known about the nature of existing treatment options or adaptations for this population. We conducted a pre-registered systematic review to: (1) identify research articles describing existing interventions for patients with ED and comorbid ASC, and to critically review evidence of their clinical effectiveness and cost-effectiveness (Review 1); (2) review the impact of ASC comorbidity on ED clinical outcomes (Review 2).

METHOD

Peer-reviewed studies published until the end of December 2020 were identified through a systematic search of the electronic databases: Medline, Embase, PsycINFO, Web of Science, CINAHL, Scopus and Cochrane Library.

RESULTS

Only one clinical pathway of treatment adaptations (the 'PEACE' pathway) was identified in Review 1 with early evidence of cost-savings and favourable treatment outcomes. ASC characteristics were shown in Review 2 to have no direct impact on physical outcomes or ED symptoms, but could be associated with higher rates of comorbidities and greater use of intensive ED treatment. Additionally, patients with ASC characteristics may benefit more from individual sessions, rather than group sessions.

CONCLUSIONS

Any new treatments or treatment adaptations may not directly impact on ED symptoms, but may be better able to support the complex needs of the ASC population, thus reducing subsequent need for intensive treatment. Future research is warranted to explore evidence of clinical and cost-effectiveness of interventions for this population.

'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

LAY ABSTRACT

This study explores autistic women's experiences of eating disorder services. About 20%-30% of people with anorexia nervosa are also autistic, and current treatments seem not to work as well for them. We interviewed 15 autistic women with experience of anorexia nervosa, 12 parents of autistic women with anorexia nervosa, and 11 healthcare professionals working in eating disorder services. We asked autistic women and parents about their experiences of eating disorder services, and we asked healthcare professionals about their experiences treating autistic women with anorexia nervosa. Participants' views were represented by three overall themes: misunderstanding autism and autistic traits, one treatment does not fit all, and improving accessibility and engagement within services. We found that autistic women face many barriers when in treatment for anorexia nervosa, often because of a lack of autism understanding within eating disorder services. Future research should look at developing anorexia nervosa treatments that can specifically help autistic individuals.

COVID-19 phobia in a boy with undiagnosed autism spectrum disorder: A case report

RATIONALE

Coronavirus disease 2019 (COVID-19) is affecting mental health profoundly. Previous studies have reported pandemic-related anxiety. Anxiety disorder and autism spectrum disorder (ASD) are common comorbidities. However, there has been no report of any patient with undiagnosed ASD who developed anxiety disorders caused by the COVID-19 pandemic. In this case report, we describe an 8-year-old Japanese boy with undiagnosed ASD who developed COVID-19 phobia, resulting in avoidant restrictive food intake disorder (ARFID).

PATIENT CONCERNS

As COVID-19 was highly publicized in the mass media and the risk of droplet infection was emphasized upon, the patient began to fear viral contamination from food, culminating in a refusal to eat or even swallow his saliva. He was admitted to a pediatric medical center in Osaka with life-threatening dehydration and was then referred to our child psychiatry department.

DIAGNOSIS

We diagnosed the patient with COVID-19 phobia resulting in ARFID. We identified ASD traits from his present social communication skills and developmental history.

INTERVENTIONS

We provided psychoeducation of ASD for the parents and administered supportive psychotherapy.

OUTCOMES

Shortly after our intervention to relieve his ASD-related anxiety, his dysphagia improved.

LESSONS

Our findings suggest that children with undiagnosed ASD may develop COVID-19 phobia. In these cases, intervention for ASD may be more appropriate than starting treatment for anxiety disorders as the first-line option. COVID-19 is the biggest pandemic in the recent past, and more undiagnosed ASD patients who develop COVID-19 phobia may seek treatment. Clinicians should consider the underlying ASD in these patients and assess their developmental history and present social communication skills.

Autistic Traits Mediate Reductions in Social Attention in Adults with Anorexia Nervosa

Anorexia nervosa (AN) is associated with difficulties in social and emotional functioning. A significant proportion of individuals with AN show autistic traits, which may influence social attention. This study examined attention to faces and facial features in AN, recovered AN (REC), and healthy controls, as well as relationships with comorbid psychopathology. One hundred and forty-eight participants' eye movements were tracked while watching a naturalistic social scene. Anxiety, depression, alexithymia, and autistic traits were assessed via self-report questionnaires. Participants with AN spent significantly less time looking at faces compared to REC and controls; patterns of attention to individual facial features did not differ across groups. Autistic traits mediated the relationship between group and time spent looking at faces.

A peer interview qualitative study exploring support for carers of people with comorbid autism and eating disorders

BACKGROUND

Carers of people with eating disorders (EDs) are known to experience a lack of support, high levels of unmet needs and resulting distress. Specific support and interventions for carers may benefit both the carer, and their loved one with an ED. Individuals with co-occurring autism and EDs may present with additional needs and difficulties relating to their Autism Spectrum Condition (ASC) that impact their carers. However, there is a lack of research exploring whether carers of people with ASC and EDs have specific support needs, and what kinds of support may be most beneficial for this population.

METHODS

This study used a qualitative interview design, utilising peer interviews. Eleven carers participated in interviews about their experiences as a carer, and their views on existing support systems and potential improvements. As the study took place during the initial UK coronavirus lockdown, the impact of the lockdown also emerged as a topic during the interviews. Interviews were transcribed and analysed using thematic analysis.

RESULTS

Five themes were identified: challenges associated with co-occurring Autism and EDs, a lack of existing support for carers from healthcare services, the personal impact of caring for someone with both ASC and EDs, ideas for how carers can be best supported, and the impact of the coronavirus on carers.

CONCLUSIONS

Carers of loved ones with both ASC and EDs described the experience as having a significant personal impact on their lives, but also experienced a lack of support from healthcare services. There was a perception that caring for someone with both an ASC and EDs presents additional challenges compared to caring for someone with an ED only, and that this population therefore requires specialised support. Recommendations for possible support options, and for further research, are outlined.

'I have more control over my life': A qualitative exploration of challenges, opportunities, and support needs among autistic university students

BACKGROUND

Autistic people are known to experience more mental health issues than non-autistic people, and the same is true among university students. These difficulties can have long-term consequences, such as dropping out of university and unemployment. Understanding the challenges autistic students face can help institutions to better support this group, while allowing celebration of the opportunities higher education offers.

METHODS

12 autistic university students took part in semi-structured interviews about their mental health, the impact of university on their mental health, and their experiences of support while in higher education. Interviews were subject to thematic analysis.

RESULTS

Three key themes were identified from autistic student accounts: Relationships, Independence, and Support. While each of these encompassed positive and negative elements, Relationships were described as tying everything together - when these were supportive, things went well, but when they were characterized by stigmatizing attitudes, students experienced much greater difficulties at university.

CONCLUSIONS

Autistic students can and do thrive at university, as shown by many of our participants. However, all faced significant challenges with their mental health at times, and experienced varying levels of support. Improving autism knowledge among staff, with emphasis on enabling better relationships, would make a significant difference to the autistic student experience.

"For Me, the Anorexia is Just a Symptom, and the Cause is the Autism": Investigating Restrictive Eating Disorders in Autistic Women

Autistic women are overrepresented among people in treatment for Anorexia Nervosa (AN). The current study aimed to: (1) better understand how AN develops and persists in autistic individuals from the perspective of autistic women, parents and healthcare professionals; (2) derive a theoretical model of restrictive eating difficulties in autism. We conducted 44 semi-structured interviews and used Thematic Analysis to identify patterns of meaning across the data. Themes related to sensory sensitivities, social interaction and relationships, sense of self and identity, difficulties with emotions, thinking styles, and a need for control and predictability. We developed a model of potential autism-specific mechanisms underlying restrictive eating difficulties. This study generated novel insights, which have the potential to inform treatment adaptations following empirical testing.

Towards an Improved Understanding of the Anorexia Nervosa and Autism Spectrum Comorbidity: PEACE Pathway Implementation

This paper describes an eating disorder service development pilot project helping clinicians implement evidence-based research for patients with anorexia nervosa and autism spectrum condition comorbidity. Currently, there are no clear guidelines or recommendations for people who have the developmental condition of autism spectrum condition and a comorbid eating disorder. The Maudsley eating disorder team is pioneering a tailored approach of adaptations for this autism and eating disorder comorbidity to improve and adapt evidenced-based treatments and improve the experience for patients, families, and clinicians involved in their care. This paper aims to support the clinical and research community to implement some of the learning and new strategies developed through the PEACE pathway. The authors aim is to collaborate with teams nationally and internationally to scale up the project to benefit patients with this comorbidity.

Carers' views on autism and eating disorders comorbidity: qualitative study

BACKGROUND

Patients with co-occurring anorexia nervosa and autism respond differently to eating disorder treatments. Previous interviews with patients with both conditions and clinicians working in eating disorder services has highlighted service and treatment adaptations might be beneficial and could improve outcomes for these individuals.

AIMS

The aim of this study was to explore carers' experiences of current treatment approaches for people with autism who have anorexia nervosa, and their views on how these can be improved.

METHOD

Ten carers of a loved one diagnosed with autism and anorexia nervosa were interviewed using a semi-structured interview schedule and the transcripts were analysed with thematic analysis.

RESULTS

Four key themes emerged from the interviews: the role of autism in anorexia nervosa, carers' problems with clinical services, the impact on carers and suggestions for future improvements.

CONCLUSIONS

Carers agreed that autism played a significant role in the development and maintenance of their daughters' anorexia nervosa. However, this comorbidity does not appear to be appropriately addressed in current treatment provisions. They described several difficulties, including problems getting an autism diagnosis and the perception that eating disorder services did not accept or adapt around the condition. This resulted in feelings of frustration and isolation for families, a scenario exacerbated by a perceived lack of support or specific resources for carers of individuals on the autism spectrum. Clinical recommendations on the basis of the current and previous studies are outlined.

Pragmatic Sensory Screening in Anorexia Nervosa and Associations with Autistic Traits

BACKGROUND

Research suggests that people with anorexia nervosa (AN) experience subjective hypersensitivity to external sensations that may require consideration in treatment. These difficulties may be particularly pronounced in people with AN and high autistic traits. The purpose of this pilot study was to explore the use of a brief screening tool to assess sensory sensitivity in individuals receiving treatment for AN, and to assess if self-rated sensitivity in AN is related to autistic traits.

METHODS

47 individuals receiving treatment for AN completed a brief sensory screening tool and self-rated their autistic traits. Individuals were also asked to give qualitative feedback on the screening tool.

RESULTS

People with AN and high autistic traits rated themselves as more hypersensitive compared to people with AN and low autistic traits. Feedback surrounding the use of the screener was positive.

CONCLUSIONS

The results of this study suggest that the use of this screener may be beneficial in eating disorder settings to help adjust and calibrate treatment to personal needs, although further research and psychometric evaluation around the clinical use of the screener is required. The finding that people with AN and high autistic traits may experience elevated hypersensitivity also warrants further exploration in future research.

The relationship of autistic traits to taste and olfactory processing in anorexia nervosa

BACKGROUND

There is a heightened prevalence of autism in anorexia nervosa (AN) compared to the general population. Autistic people with AN experience a longer illness duration and poorer treatment outcomes. Whether sensory differences in autism could contribute to altered taste and smell as a potential maintaining factor in AN is under-explored. The aim of this study was to explore whether autistic traits are associated with taste and olfaction differences in AN.

METHODS

The study recruited n = 40 people with AN, and n = 40 healthy controls (HC). Smell sensitivity was measured using the Sniffin' Sticks test. Taste sensitivity was measured using taste strips. Participants self-rated their autistic traits using the Autism Spectrum Quotient.

RESULTS

There were no significant differences on taste and olfactory outcomes between people with AN and HC. These findings did not change after controlling for the heightened levels of autistic traits in the AN group. No relationship between taste and smell outcomes and autistic traits were identified within the AN group.

LIMITATIONS

The current study is not able to draw conclusions about taste and smell processing in co-occurring autism and AN as it only measured levels of autistic traits, rather than comparing people with and without an autism diagnosis.

CONCLUSIONS

No significant associations between autistic traits and taste and smell processing in AN were identified. Future research should consider further exploring this area, including by comparing autistic women to women with AN.

Autism spectrum disorder traits are associated with empathic abilities in adults with anorexia nervosa

BACKGROUND

Social and emotional difficulties have been identified as key factors in the development and maintenance of anorexia nervosa (AN). However, few studies have investigated the influence of comorbid psychopathology on social cognition. The aim of the current study was to examine perception of nonverbal communication and empathy in AN using ecologically valid, performance-based measures, and to explore associations with comorbid psychopathology (anxiety, depression, autism spectrum disorder (ASD) traits, alexithymia, and social anxiety).

METHODS

In this cross-sectional study, the Multifaceted Empathy Test (MET) and the Mini Profile of Nonverbal Sensitivity (MiniPONS) were administered to 51 adults with AN, 51 recovered AN (REC), and 51 healthy controls (HCs). Comorbid psychopathological traits were assessed using self-report questionnaires and the Autism Diagnostic Observation Schedule - 2nd edition (ADOS-2).

RESULTS

Individuals with AN showed reduced affective empathy to positive stimuli compared to HCs, and a trend towards lower vocal prosody recognition scores relative to REC. Around a quarter of AN and REC scored above the clinical cut-off for ASD on the ADOS-2, and high ASD symptoms predicted lower cognitive and affective empathy scores.

LIMITATIONS

The study is cross-sectional, future research would benefit from examining social-cognition performance and comorbid psychopathology longitudinally.

CONCLUSIONS

The findings highlight the importance of ASD symptoms in empathy dysfunction in those with a lifetime history of AN. Future research should explore whether treatment adaptations to accommodate for differences in social-cognitive abilities may be helpful in the treatment of AN.

Autistic traits in mentalization-based treatment for concurrent borderline personality disorder and substance use disorder: Secondary analyses of a randomized controlled feasibility study

Autism is suggested to be a dimensional construct and often represents a comorbid state. However, research on the clinical implications of the presence of autistic traits is scarce. This study aimed to investigate the impact of subclinical autistic traits in mentalization-based treatment (MBT) for concurrent borderline personality disorder (BPD) and substance use disorder (SUD). Based on the data of a randomized controlled feasibility study by Philips, Wennberg, Konradsson, and Franck (2018), secondary analyses were conducted. It was tested, if patients' (N = 46) levels of autistic traits were associated with treatment outcome measured in the course of and after treatment using interviews and self-report measures. Participants' autistic traits were not associated with the change in the severity of BPD throughout and at the end of the treatment. However, results showed associations between autistic traits and the change in patients' consumption of alcohol in the course of MBT. Furthermore, there was an association between autistic traits and the change in mentalizing capacity at the end of MBT, indicating that elevated autistic traits were associated with an improvement in mentalizing capacity. Autistic traits on a subclinical level do not appear to be a complicating factor in MBT for concurrent BPD and SUD. On the contrary, in terms of mentalizing capacity autistic traits might be associated with a larger potential for improvement or facilitate treatment outcome. Further research is needed to explore the role of higher autistic traits in treatment of this special patient group.

Visual scanning during emotion recognition in long-term recovered anorexia nervosa: An eye-tracking study

OBJECTIVE

To examine Facial Emotion Recognition (FER) and visual scanning behavior (eye-tracking) during FER in women long-term recovered from teenage-onset anorexia nervosa (recAN) with and without autism spectrum disorder (±ASD) and age-matched comparison women (COMP), using a sensitive design with facial emotion expressions at varying intensities in order to approximate real social contexts.

METHOD

Fifty-seven 38-47-year-old women (26 recAN of whom six with ASD, 31 COMP) participated in the study. They completed a non-verbal FER task, consisting of matching basic emotions at different levels of expression intensity with full emotional expressions. Accuracy, response time and visual scanning behavior were measured.

RESULTS

There were no differences between recAN-ASD and COMP in FER accuracy and visual scanning behavior during FER, including eye viewing and hyperscanning. In an exploratory analysis, recAN+ASD were more accurate than recAN-ASD in identifying expressions at low intensity, but not at medium or high expression intensity. Accuracy was not associated with the extent of attention to the eye region.

DISCUSSION

Our data indicate that women long-term recovered from adolescent-onset AN do not have deficits in basic FER ability and visual scanning behavior during FER. However, the presence of comorbid ASD might affect face processing in recovered AN. Future studies investigating basic FER in acute and recovered AN and other conditions need to ensure that the stimuli used are sensitive enough to detect potential deficits.

Same behaviours, different reasons: what do patients with co-occurring anorexia and autism want from treatment?

Research suggests that up to one in four individuals with anorexia nervosa (AN) may be on the autistic spectrum, and that these autistic traits may not have been recognized or diagnosed prior to eating disorder (ED) treatment. Significantly, these heightened autistic traits are associated with poorer treatment outcomes, suggesting that treatment may need to be adapted for this population. The purpose of this study was to explore with people with AN on the autistic spectrum their experiences of ED treatment, and their views on what needs to be changed. Women with AN (n= 13), either with an autism diagnosis or presenting with clinically significant levels of autistic traits, were interviewed on their experiences of treatment and potential improvements. Interviews were analysed using thematic analysis. The findings suggest that this population experience unique needs associated with their autism that are not being met by standard ED treatments, and recommendations are made for potential future adaptations. Future research into a more systematic approach for treatment adaptations for this population, including education programmes for clinicians, could potentially lead to better treatment experiences.

Do autism spectrum disorder and anorexia nervosa have some eating disturbances in common?

A possible overlap between autism spectrum disorder (ASD) and anorexia nervosa (AN), in terms of both behavioural and cognitive features, has led to new areas of research. The aim of the present study was to examine the occurrence of eating behaviours frequently seen in ASD among adolescents and young adults with AN. The participants were females within the age range 15-25 years: 36 with current AN (32 were followed up after 1 year), 19 with ASD, and 30 healthy females. The participants completed the SWedish Eating Assessment for Autism spectrum disorders (SWEAA) and the Autism Spectrum Quotient tool (AQ). AN groups had significantly higher SWEAA scores than the healthy comparison group, also when patients had gained weight. Typical autistic eating behaviours, such as selective eating, were more common in the AN groups than in the ASD group. This is the first time that SWEAA has been implemented in an AN population. Eating behaviours frequently seen in ASD seem to be frequent in AN and some remain also after weight gain.

Anorexia Nervosa, Autism, and the ADOS: How Appropriate Is the New Algorithm in Identifying Cases?

Thirty years of scholarship has suggested that anorexia nervosa (AN) may be a "female presentation" of autism, supported by work which has found elevated rates of autism traits and diagnoses among women with clinical levels of AN. These traits are often assessed using the Autism Diagnostic Observation Schedule 2nd Edition (ADOS-2), considered the "gold-standard" tool. Recently, the authors of the ADOS-2 revised the diagnostic algorithm for the adult version of the assessment-the one most often used with AN patients. We therefore examined differences in the scores, rates of diagnosis, and correlations with other mental health issues between the two diagnostic algorithms among women with and without AN. One hundred seventy-five women with current AN, who had recovered from AN, and with no history of AN, between the ages of 12 and 53, took part in an ADOS-2 assessment. Their scores were then calculated according to both the original and the new algorithms. The new ADOS-2 algorithm identifies more women as potentially being on the autism spectrum than the old algorithm. Under both algorithms, more currently ill AN patients were identified as potentially being autistic than those with no history of AN. Recovered individuals represented a midpoint between the scores of those with and without AN on both algorithms. There were no correlations with mental health scores in any group, meaning that the new ADOS-2 algorithm is not falsely identifying anxious behaviors or depressive presentations as signs of autism in this group. Overall, we found that more AN patients and recovered individuals scored above cut-off on the new ADOS-2 algorithm, suggesting that women who experience AN may have more autistic traits, which in part persist following weight restoration and recovery. However, the ADOS-2 should not be used alone but in combination with broader clinical assessments to determine whether an autism diagnosis is appropriate for these women.

Effectiveness of emotional skills training for patients with anorexia nervosa with autistic symptoms in group and individual format

OBJECTIVE

The aim of this study was to examine the effectiveness of CREST interventions in individual and group formats for adult anorexia nervosa. Furthermore, this study also aims to analyse whether patients with high levels of autistic symptoms respond differently.

METHODS

Participants' self-report measures were taken before and after individual and group interventions (N = 66 and N = 62, respectively). Mixed effects analysis was used to analyse overall response to both formats and assess interaction with autism symptoms.

RESULTS

Significant improvements were observed for patients' alexithymia in individual format, and motivation increased for participants in both interventions. Significant interactions were observed between alexithymia, social anhedonia, and autism symptoms in individual format and alexithymia in group format. No interactions between autism and time were observed for either format.

CONCLUSIONS

CREST in both formats offers participants improvements in social-emotional and motivational domains. Patients with high levels of autism symptoms also score high on both social anhedonia and alexithymia measures, but this does not affect their response to treatment.