The relationship

of
.
eating disorders to
ASD

Prof. Janet Treasure

j.treasure@iop.kcl.ac.uk
www.eatingresearch.com

Overview
What are eating disorders
Links with ASD?
Cognition Set shifting
Cognition Central Coherence
Social cognition

Affective
Disorder
OCD
spectrum
EDNOS
AN
BN
Autistic
spectrum

Bipolar
spectrum

Addiction
spectrum
ADHD

The comorbidity of Eating Disorders

AN as empathy disorder
AN autistic spectrum
disorder
Narrow interest, repetitive
behaviour
Not understand family
distress
(Gillberg et al 1994, Wentz et al 2009)

Comorbidity AN & ASD

Anorexia nervosa and autism co-segregate
within families (Gillberg 1983, )
20% autistic spectrum disorder (ASD) of cohort
of AN ascertained from community at age 15.
Continuing social impairments & poor outcome
(Gillberg et al 1994, Wentz et al 2009).
26/ 30 (53%) adult female inpatients - childhood
onset neuropsychiatric diagnosis. (23% ASD,
17% (ADHD), 27% tic disorder (Wentz et al
2005 ).

At Risk Population
(Coombs et al 2010)

Age: 13 . School children m=61 f=71

ASD traits correlate EAT traits
Attention to detail and communication
difficulties predict EAT score with social
skills protecting.

Broader Autism Phenotype

Autism Traits
Systematising Traits
Empathising
Male Brain
( Hambrook et al 2008, BaronCohen et al 2011, Lopez et al 2011)

A gender comparison high function

ASD (Lai et al 2011)
Male

Female

ADIR

RME

22

22

AQ

++

EQ/SQ

Sensory

++

ADOS
Social
communication

+++

Cognitive overlaps AN &ASD

ASD behaviours related to three cognitive
domains/theories:
Executive dysfunction-set shifting.
Weak central coherence.
Poor theory of mind (low social cognition)

10

10

10

10

Rigidity
.Difficulty in changing cognitive

set.
Once a rule is learned it is
difficult to shift.
Mastery at adhering to laws of
thermodynamics.
Linked to childhood OCPD
features

Tchanturia et
al 2005,
2006
Roberts et al
2007

1. What is the worry about food?

3. It s as if you have a
calculator in your head
totting up the intake
and output. You are
scientific about these
laws of
thermodynamics what
things go in your rule
system.

The therapist
explores how detail
of the AN
rules impacts on
eating

2. I want to keep and maintain a

specific weight and in order to do that
I know there are rulesI have to
control my intake
4. Well there is the amount of exercise I
do but that gets addictive more and more.
Walking at right angles rather than
curves
The amount I sleep, I try to keep it short
as you use fewer calories.
I would restrict the amount of tooth paste
because fear of extra calories.
Avoid smelling food, if you can smell it
there must be something there in your
body you could absorb
If I cut my hair I would weigh that for my
calculations
If my watch broke I would have to put
something heavy on my wrist to
compensate
If I lost a nose stud- I would have to have
a replacement

Embedded Figure Test

Fragmented Figure Task

A
v
e
r
a
g
ef
r
a
m
ew
h
e
np
ic
t
u
r
eid
e
n
t
if
ie
d(o
u
to
f8
)

Acute AN> BN > Recovered> HC : Correlation with BMI

0
ED

Controls

Detail vs. Global Imbalance

Inability to see bigger picture i.e.
Not seeing the wood for the trees.
Heightened perceptual
awareness.
Analytical, detailed focus.
Difficulty extracting gist.

Lopez et al 2008a,
2008b, 2008c,
2008d

Does your attention to detail have a negative side? For example are
you hyper-sensitive to slight errors or mistakes eg music off key,
flavours discordant, details off in some way?
So everyone has their own cereal, everyone likes different cereals, so we have so
many, and um we all like different cereals, and at the moment I like wheetabix and
because everyone has two wheetabixs and they are even because there are 24
wheetabix in the thing, because it is supposed to be even, because everyone is
supposed to have two and thats whats normal, which I am trying to be normal.
And, things that annoy me, it got down to the end one day and there was one left, I
took two and I was like why is there one left? because I had two, because I am
the only one that eats this. And then I said to mum, obviously someone else has
had some wheetabix and I was like but that means they have only had one and
thats not normal and so she was like maybe they had one wheetabix and some of
their cereal She was trying to make me relax. dad he sort of brought it up a
few days later, he goes, well I am worried that you start counting things

Food and Exercise Rituals (Age 11 yrs)

I exercised to relieve anxiety. I set myself daily
exercise goals that I had to achieve to prove to
myself that I was not a worthless person.
Same exercise routine, same times of day,
sometimes more, but never less. If I didnt achieve
my exercise goals I sometimes cut myself or sat in a
cold bath as punishment.
Cut out all bad foods and made lists/plans of what I
could eat and what I couldnt eat.
Made lists of calories, grams of fat, protein and
carbohydrate in all food consumed. Reading nutrition
charts became an enjoyable hobby.
My food and exercise routines felt like my life-plan. If
I followed this plan precisely, everything would be
OK.

Cognitive overlaps AN &ASD

ASD behaviours related to three cognitive
domains/theories:
Executive dysfunction-set shifting.
Weak central coherence.
Poor theory of mind (low social cognition)

Baseline Low Social worth

Loneliness, shyness, and
inferiority in childhood and
adolescence (Fairburn et al 1999)
Social anxiety (Penas lledo et al 2010)
Submissive and striving
behaviours (Connan et al.,2003
2007, Troop et al., 2008, Troop et al.,
2003).

Punish vs. reward

Attention bias to
negative

Attention bias
Away from positive

Attention to Accepting/Rejecting faces

Immediate

Delay

AB Accepting Rejecting faces T2

AB Accepting Rejecting faces T1

30

20

25

15

20

10

15

5
ED

0
-5

ABRej

ABAcc

REC
HC

10

ED

REC

HC

-10

-5

-15

-10

-20

-15
-20

-25

ABRej

ABAcc

Reduced Emotional Regulation

--

ED longer to name the colour for faces.

More distracted by non verbal emotional signalling of
threat and ambiguous faces
Large effect in acute state. Medium effect in recovered

Harrison et al 2009, 2010

H Davies
K
Tchanturia
U Schmidt

Emotional Expression
Congruence
expression/experience
HC

AN

Attention
HC

AN

Impaired Reading Mind Others

Oldershaw et al. (2010.)

OK

Moderate effects which other than eyes task improve after recovery

Understanding
how others think
not just what they
say

About 20% of people

with anorexia nervosa
have some difficulty
with this.
Tchanturia et al 2004,
2009.

Just

back up little dear,

so you wont cut my head
off

Interpersonal Difficulties
Age 8-9 yrs: traumatic events which confused me
and made me feel that I was a bad person.
Age 9-11 yrs: bullied by a pack of girls. This
increased my fear of other people and my sense of
being abnormal and worthless.
Flirtatious comment by older male schoolteacher led
me to be terrified of ALL men.
I felt different as if I was all wrong. I felt I didnt fit
in anywhere. I didnt know who I was, and I was
terrified of the future.

Conclusion
Some of the social cognition deficits may
be secondary to the illness .
Others such as extreme shyness, social
phobia may be innate

The patients voice:

Despite being weight recovered, the obsessional eating, tendency for
rituals and desire for control/predictability, rigidity and order are all
things I still struggle with.
If I fail to eat a meal in a certain way I still panic - it feels 'wrong'. The
panic is not linked to my weight or body image.
I had rituals as a young child, long before the trauma that triggered
my anorexia nervosa. My father is the same.
The way that I reacted to the trauma of sexual abuse was to engage in
exercise and food rituals, which seemed to contain my anxiety.
I felt particularly bound by the exercise rituals, which I always
performed at the same time of day, on the same treadmill in the gym
and to the point of physical exhaustion.
Any change of routine and I panicked. The panic also had 'meaning' as
well as feeling 'wrong' - e.g. 'I haven't managed to complete the usual
number of minutes at a particular intensity and so I am a failure and
not worthy of existing'.

Summary of Findings
Currently ill AN patients have impaired set
shifting and detail/global balance similar degree
to those observed in ASD.
Currently ill AN patients have impaired emotion
recognition and eToM ability similar degree to
those observed in ASD.
.Recovery is associated with improvement in
some aspects of social emotional functioning
and more flexibility.

Affective
Disorder
OCD
spectrum
EDNOS
AN
BN
Autistic
spectrum

Bipolar
spectrum

Addiction
spectrum
ADHD

The comorbidity of Eating Disorders

Conclusions
All acute AN can have Pseudo ASD
features
Also 20% may be high functioning female
Aspergers

The patients voice: post recovery

I am 55 now and recovered from AN in my early 30s
after 10 years of illness.
However I have continued to struggle with episodes of
depression and am now on long-term antidepressants.
I continue to find life very difficult and keep getting into
difficulties with jobs - expecting people to be perfect, and
rules to be logical.
There seems to be no end to it although I try desperately
to be tolerant and shrug my shoulders.
I am also very socially isolated
I am divorced with two lively teenage boys.

Final Conclusion
AN & ASD share weak coherence and this may
be a risk factor possibly associated with OCPD
traits.
Starvation increases rigidity & OCPD traits.
Starvation decreases social cognition.
Starvation decreases emotional regulation.
Starvation shifts reward from people onto food
alone.
People with acute AN resemble ASD
People with ASD at risk of eating disorders

Acknowledgements

Nina Jackson (RIED), NIHR, BRC

Triad of three basic problems in

ASD (Wing and Gould)
i. Impairment of social interaction
This refers to the marked reduction of non-verbal signs
of interest in and pleasure from being with another
person .
ii. Impairment of social communication
This refers to the decreased ability to converse nonverbally and verbally with another person, sharing ideas
and interests or to negotiate in a positive friendly way.
iii. Impairment of social imagination
This is the decreased capacity to think about and predict
the consequences of ones own actions for oneself and
for other people.

AQ: Short traits

Detect small sound

See details vs big picture
Difficult to multi-task
Not easy to get back task when interrupted
Not find easy to read between lines
Not find easy to know someone listening to me bored.
When read story difficult to know intentions
Like collect information about categories eg birds, plants
Not easy to know what people think via faces.
Difficult to know peoples intentions.

Girls With Social and/or Attention

Deficits: N= 100, Age 7-16 Clinic Attenders
(Kopp et al 2010)

Comorbidity of girls ASD

35% OCD
30% Social phobia
40% Specific Phobia
35% > 2 anxiety disorders
5% Eating Disorder
40% Sleep Disorder
35% depression