Using the Autism-Spectrum Quotient to Measure Autistic Traits in Anorexia Nervosa: A Systematic Review and Meta-Analysis

Neuroanatomical associations with autistic characteristics in those with acute anorexia nervosa and weight-restored individuals

Common neuroanatomical regions are associated with both states of anorexia nervosa (AN) and autistic characteristics, but restoration of body mass index (BMI) has been associated with decreased presentation of autistic characteristics in some individuals with AN. This study aims to examine neuroanatomical correlates associated with autistic characteristics in those with acute anorexia nervosa (ac-AN) and those previously diagnosed with AN but whose weight has been restored (WR). In total, 183 individuals (healthy controls [HCs] = 67; n[ac-AN] = 68; n[WR] = 48) from the Brain imaging of Emotion And Cognition of adolescents with Anorexia Nervosa (BEACON) study were included, with autistic characteristics determined in both ac-AN and WR individuals (n = 116). To further examine BMI, ac-AN and WR group associations were compared. Random forest regression (RFR) models examined whether autistic characteristics and morphology of the anterior cingulate cortex (ACC), middle frontal gyrus (MFG), and orbitofrontal cortex (OFC) were able to predict future levels of social anhedonia and alexithymia. Group-wise differences were identified within the volume and surface area of the MFG and OFC, which were unrelated to BMI. Autistic characteristics were inversely associated with MFG and ACC volume, with differences in associations between ac-AN and WR groups seen in the surface area of the MFG. RFR models identified moderate-to-weak performance and found that autistic characteristics were not important predictive features in a priori and exploratory models. Findings suggest that the presence of autistic characteristics in those with ac-AN are associated with the volume of the MFG and are unrelated to BMI restoration.

Evaluating the efficacy of radically open dialectical behavior therapy (RO-DBT) in patients with anorexia nervosa: study protocol for a randomized controlled clinical trial

BACKGROUND

Anorexia nervosa (AN) is a severe and disabling disorder, with relapse rates as high as 50% after the first episode, posing a significant challenge for clinicians. Most therapies excessively focus on nourishment, resulting in temporary weight restoration but with no improvements in general well-being and quality of life. Radically Open Dialectical Behavior Therapy (RO-DBT) is a transdiagnostic treatment designed to address overcontrol, a key aspect in the functioning of patients with AN. To date, no clinical trial (CT) has shown its efficacy in these patients or evaluated its neurobiological mechanism of action.

METHODS

A randomized CT in weight restored adult AN patients will be conducted, with one group receiving treatment as usual (TAU) and the other TAU plus RO-DBT, with the main outcome being quality of life. Secondary variables will include eating disorders (EDs) symptoms, overcontrol characteristics, autistic traits, and neuroimaging changes.

DISCUSSION

The results will address a gap in knowledge regarding AN treatment, with the expectation that patients receiving TAU with RO-DBT will exhibit improved quality of life and experience fewer relapses at the one-year follow-up. This is the first study examining neuroimaging changes in RO-DBT to better understand its underlying mechanisms.

TRIAL REGISTRATION

The study has been registered in ClinicalTrials.gov in September 22, 2023. It can be found in https://classic.

CLINICALTRIALS

gov/ct2/show/NCT06050421 .

TRIAL REGISTRATION NUMBER

NCT06050421.

"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.

Autistic traits are associated with the presence of post-traumatic stress symptoms and suicidality among subjects with autism spectrum conditions and Anorexia nervosa

INTRODUCTION

Recently, growing attention has been paid to the presence of undetected Autism Spectrum Disorder (ASD) and subthreshold autistic traits (ATs) among females, and on their gender specific manifestation. In particular, the recent literature focused on the overlap between autism spectrum and eating disorders, which share with ASD not only features such as of cognitive inflexibility but also a link with trauma- and stress-related disorders. In this framework, we aimed to assess the interaction between ATs, stress- or trauma-related symptoms, and the risk of suicidality in subjects with different mental conditions.

METHODS

184 subjects were divided in three diagnostic groups: Broad autism phenotype (BAP), Anorexia Nervosa (AN) and Healthy Controls (HCs) and assessed with the Adult Autism Subthreshold Spectrum (AdAS Spectrum) questionnaire, the Trauma and Loss Spectrum - Self Report (TALS - SR) questionnaire and the Mood Spectrum - Self Report (MOODS - SR) questionnaire.

RESULTS

AN subjects reported notable ATs reinforcing the hypothesis that AN might represent an atypical ASD manifestation more common in women. Furthermore, both AN and BAP subjects showed a considerable presence of trauma/stress associated symptoms. The dimension of trauma/stress related symptoms also appeared to be associated with ATs, and to significantly mediate the relationship between ATs and suicidality risk. Lastly, AN were found to have a stronger correlation with the presence of post-traumatic stress symptoms.

CONCLUSIONS

the results support the presence of a link between ATs and AN. Moreover, AN seems to be more strongly associated with post-traumatic stress symptoms than BAP. ATs and trauma/stress related symptoms may interact in shaping suicidality risk in these patients.

A Mixed Method Systematic Review Into the Impact of ED Treatment in Autistic People and Those With High Autistic Traits

OBJECTIVE

Our understanding of the impact of eating disorders (ED) treatment in Autistic people remains elusive. Research has begun to explore ED treatment outcomes and experiences in this population, however current understandings are poorly integrated. The current review therefore sought to explore the impact of ED treatment on Autistic people and those with higher Autistic traits.

METHOD

A convergent, segregated approach was used, independently evaluating quantitative then qualitative studies before integrating findings into a coherent narrative synthesis.

RESULTS

Autistic people and people with higher Autistic traits report poorer experiences of treatment and may be at increased risk of inpatient admission and prolonged inpatient treatment, possibly explained by difficulties with treatment timeframes and a lack of autism-informed support. Both groups reported similar improvements in ED symptoms and BMI. Higher rates of psychosocial difficulties pre-and post-treatment were reported in those with higher Autistic traits, and emotion-focused interventions were felt to be particularly relevant to Autistic presentations of EDs. Concerns were reported as to how well aligned group-based programs and cognitive-based interventions are for Autistic individuals and those reporting higher Autistic traits.

DISCUSSION

Future research in diagnosed autism samples is urgently needed to develop a more robust understanding of Autistic outcomes and experiences. Review findings demonstrate the need for increased understanding of ED presentations and the possible need for treatment adaptations, for Autistic people or those with higher Autistic traits.

Exploring the relationship among hikikomori tendencies, autistic traits, computer game use and eating disorder symptoms

OBJECTIVE

The hikikomori phenomenon has recently gained growing global interest, and evidences of its association with other psychopathological dimensions are slowly but steadily emerging. We aimed to evaluate the presence and correlates of hikikomori tendencies in an Italian University population, focusing on its relationships with autism spectrum, pathological computer gaming, and eating disorders. In particular, to our knowledge, no study has yet systematically evaluated the latter association, using psychometric instruments tailored to assess eating disorder symptoms.

METHODS

2574 students were recruited via an online survey. All participants were assessed with the Hikikomori Questionnaire-25 (HQ-25), the Adult Autism Subthreshold Spectrum Questionnaire (AdAS Spectrum), the Eating Attitude test-26 (EAT-26), and the Assessment of Internet and Computer Game Addiction (AICA-S).

RESULTS

The results outlined how hikikomori risk was significantly correlated to autistic dimensions, altered eating behaviors, and videogame addiction. The closest relationship was detected with the autism spectrum. Interestingly, pathological computer gaming, most autistic dimensions, and EAT-26 oral control emerged as significant predictors of a greater risk for hikikomori, while the proneness to inflexibility and adherence to routine emerged as negative predictors.

CONCLUSIONS

Our findings support the association among hikikomori, autism spectrum, pathological computer game use, and eating disorder symptoms.

Exploring the links between sensory sensitivity, autistic traits and autism-related eating behaviours in a sample of adult women with eating disorders

This study examined the presence of autistic traits in a sample of adult women diagnosed with different Eating Disorders (ED), and explored the concurrent role of autistic traits and sensory sensitivity in influencing both their eating disorder symptomatology and their autism-related eating behaviours. Seventy-five women with different ED (Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder, Other Specified Feeding or Eating Disorder) completed the Eating Attitude Test (EAT-26), the Autism Quotient (AQ), the Ritvo Autism Asperger Diagnostic Scale-Revised (RAADS-R), the Sensory Perception Quotient - Short Form 35 item (SPQ-SF35) and the Swedish Eating Assessment for Autism Spectrum Disorders (SWEAA). Twelve percent of participants scored above the cut-off on both the AQ and the RAADS-R, while 68% scored above the cut-off on the RAADS-R only. A mediation analysis revealed that the association between sensory sensitivity (SPQ-SFR35) and scores on both the EAT-26 and the SWEAA was significantly mediated by the presence of autistic traits (RAADS-R). These findings, first, confirm the presence of autistic traits in individuals with ED; second, they show that a lower sensory threshold (i.e., a higher sensory sensitivity) is associated with a higher presence of autistic traits which were, in turn, positively associated with dysfunctional eating behaviours typical of ED and ASD. This study ultimately highlights the importance of further research on autistic traits across all diagnostic categories of ED.

Autistic traits and perspective taking in youths with anorexia nervosa: an exploratory clinical and eye tracking study

BACKGROUND

Despite their apparent dissimilarity, Anorexia Nervosa (AN) and Autism Spectrum Disorder (ASD) share many features, especially in terms of social and emotional difficulties. In recent years, empathic abilities in AN have been frequently assessed using self-report measures. Otherwise, the director task (DT) has been used to investigate the ability to take the visual perspective of another individual in a communicative context, using eye-tracking technology. The aim of the current study was to test the presence of autism-relevant features in AN, through: (i) comparing self-reported autistic traits and empathic abilities in a group of young inpatients with AN and age/gender matched healthy controls (HC); (ii) comparing performance on the director paradigm.

METHODS

The participants were females in the age-range between 11 and 18 years: 24 with AN and 23 HC. Autistic traits, empathic abilities, and severity of the eating disorder were respectively measured using: the Autism Quotient (AQ), the Interpersonal Reactivity Index (IRI), and the Eating Disorder Inventory-3 (EDI-3). Both groups performed a computerized task in which a director instructed them to move objects placed on a set of shelves using a mouse, while their eye gaze was tracked. A total of 36 shelf configurations, divided into three categories (with dimensional distractor - with spatial distractor - control), were created.

RESULTS

Subjects with AN showed higher autistic traits than HC. Eye-tracking data revealed that subjects with AN took longer to decide which object to select and where to move it, both in distractor-trials and in control-trials. In the AN group, we found a significant negative correlation between the total score of the AQ and the number of fixations to the irrelevant object in the dimensional control condition -in which the subjects were asked to focus on dimensional aspects of the object (large-small)-.

CONCLUSIONS

Autistic traits were over-represented in a group of young inpatients with AN. Through the use of eye-tracking technology, this exploratory study documented some differences between AN inpatients and HC in their online processes during the perspective taking tasks, which could be considered a target of tailored intervention. A larger sample of patients is needed to confirm these preliminary findings.

The clinical characteristics of autistic women with restrictive eating disorders

BACKGROUND

Autistic women are at high risk of developing restrictive eating disorders (REDs), such as anorexia nervosa.

AIMS

This study provides an overview of the clinical characteristics of autistic women with REDs to (i) enhance understanding of increased risk, and (ii) support the identification of autistic women in eating disorder services.

METHOD

We compared self-reported autistic and disordered eating characteristics of: autistic participants with REDs (Autism + REDs; n = 57); autistic participants without REDs (Autism; n = 69); and women with REDs who are not autistic (REDs; n = 80). We also included a group of women with high autistic traits (HATs) and REDs, but no formal autism diagnosis (HATs + REDs; n = 38).

RESULTS

Autism + REDs participants scored similarly to Autism participants in terms of autistic characteristics and to REDs participants in terms of experiencing traditional disordered eating symptoms. Autism + REDs participants were distinguished from both groups by having more restricted and repetitive behaviours and autism-specific eating behaviours related to sensory processing, flexibility and social differences. HATs + REDs participants showed a similar pattern of scores to Autism + REDs participants, and both also presented with high levels of co-occurring mental health difficulties, particularly social anxiety.

CONCLUSION

The presentation of autistic women with REDs is complex, including both traditional disordered eating symptoms and autism-related needs, as well as high levels of co-occurring mental health difficulties. In eating disorder services, the REDs presentation of autistic women and those with HATs should be formulated with reference to autism-specific eating behaviours and co-occurring difficulties. Treatment adaptations should be offered to accommodate autistic characteristics and related needs.

Potential mechanisms underlying the association between feeding and eating disorders and autism

There is a reliable association between autism and Feeding and Eating Disorders. Concerningly, where these two conditions co-occur, clinical outcomes of Feeding and Eating Disorders are significantly worse, and treatment less effective, than when the Feeding and Eating Disorders occur in neurotypical individuals. Problematically, the reason for the association between autism and Feeding and Eating Disorders is poorly understood, which constrains advances in clinical care. This paper outlines several possible mechanisms that may underlie the observed association and suggests ways in which they may be empirically tested. Mechanisms are split into those producing an artefactual association, and those reflecting a genuine link between conditions. Artefactual associations may be due to conceptual overlap in both diagnostic criteria and measurement, Feeding and Eating Disorders causing transient autistic traits, or the association being non-specific in nature. A genuine association between autism and Feeding and Eating Disorders may be due to common causal factors, autism directly or indirectly causing Feeding and Eating Disorders, and Feeding and Eating Disorders being a female manifestation of autism.

Cognitive and emotional empathy in acute and remitted anorexia nervosa: a systematic review

Background

Impairments in empathy are well established in anorexia nervosa (AN). It is unclear, however, whether these deficits only occur in the acute phases of AN due to neurocognitive impacts of starvation (often referred to as context-dependent, or state-like), or if deficits remain once remission has been achieved (trait-like). This debate is commonly referred to as the 'state vs trait' debate.

Objective

This systematic review aims to summarise existing literature regarding empathy in AN, and to investigate whether empathy deficits in AN are state- or trait-based.

Method

A total of 1014 articles were identified, and seven articles remained after the screening process. These seven articles, comparing empathy across three groups (acute AN, remission of AN, and non-clinical controls), were evaluated and summarised in accordance with PRISMA guidelines. Articles were required to have included all three groups and report on either cognitive empathy and/or emotional empathy.

Results

The majority of studies were of satisfactory quality. The results identified were inconsistent, with few articles lending some support to the 'state' hypothesis and others producing nonsignificant results.

Conclusions

There is minimal literature comparing empathy in acute and remission phases of AN. While there were some inconsistencies in included articles, some data indicate that there may be slight improvements to emotional and cognitive empathy following recovery of AN. Further research is needed to better enrich knowledge regarding the role of state vs trait with regard to neurocognitive difficulties experienced by individuals with AN.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=335669, identifier CRD42022335669.

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.

The Associations Between Camouflaging, Autistic Traits, and Mental Health in Nonautistic Adults

Background

Camouflaging is frequently reported in autistic people and entails the disguising of autistic traits in social situations. Camouflaging is associated with poor mental health in autistic people. This study examined the manifestation of camouflaging in a nonautistic sample, examining the relationship between autistic traits, self-reported camouflaging, gender, and mental health.

Method

In total 110 nonautistic adults completed standardized self-report questionnaires that measured autistic traits, mental health symptoms, and camouflaging behaviors. Hierarchical multiple linear regression models were used to analyze data and examine the unique contributions of autistic traits and camouflaging to mental health.

Results

Self-reported autistic traits were associated with increased symptoms of poor mental health. However, autistic traits were not associated with mental health symptoms when controlling for self-reported camouflaging, and self-reported camouflaging predicted increased mental health symptoms over and above the effects of autistic traits. Women had poorer mental health than men in our sample, and in women there was a stronger relationship between camouflaging and mental health than in men.

Conclusions

Camouflaging may contribute to poor mental health outcomes in the general population, just as it does for autistic people, to the extent that camouflaging more clearly relates to mental health profile than self-reported autism traits. This suggests camouflaging is an important construct for understanding mental health in general, and for exploring the complex relationship between autism and autistic traits.

The effect of autistic traits on prosocial behavior: The chain mediating role of received social support and perceived social support

ABSTRACT

There is growing evidence that the defining characteristics of autism spectrum disorder are distributed across the general population; therefore, understanding the correlates of prosocial behavior in individuals with high levels of autistic traits could shed light on autism spectrum disorder and prosocial behavior. In this study, the mechanism underlying the influence of individuals’ autistic traits on their prosocial behavior was explored by conducting a questionnaire survey of 414 Chinese college students. The results showed that autistic traits can influence individuals’ prosocial behavior not only through the separate effects of received social support and perceived social support but also through the chain mediating effects of received social support and perceived social support; however, the direct effect of autistic traits on individuals’ prosocial behavior is not significant. This study is conducive to understanding the internal mechanism underlying the relationship between autistic traits and prosocial behavior. Future work is required to further investigate the clinical autism spectrum disorder samples and cross-cultural applicability of the model found in this study.

Autistic traits, sensory sensitivity and eating disturbances in a sample of young adults referring to a generalized mental health clinic

PURPOSE

The relationship between autistic traits and eating disturbances has been given considerable attention over the last decades. The rise of a dimensional approach to psychopathology has expanded the way we think about autism, acknowledging that subthreshold autistic manifestations span across the general population and are more pronounced in psychiatric patients. Here we investigated the prevalence of eating disorders and its potential relationship with autistic traits and sensory sensitivity in a group of patients who were referred for the first time to a mental health outpatient clinic, without a formal diagnosis yet.

METHODS

259 young adults (between 18 and 24 years old) completed: the Eating Attitude Test (EAT-26), the Swedish Eating Assessment for Autism Spectrum Disorders (SWEAA), the Autism Quotient (AQ), the Ritvo Autism Asperger Diagnostic Scale-Revised (RAADS-R), and the Sensory Perception Quotient-Short Form 35 item (SPQ-SF35).

RESULTS

23.55% of participants scored above the cut-off at the EAT-26, suggesting that they presented a risk for eating disorders and should be assessed by a specialized clinician; associations emerged between hypersensitivity in the touch and vision domain and both the EAT-26 and the SWEAA; the presence of autistic traits was largely associated with eating disturbances.

CONCLUSIONS

This study underlines the significance of the eating domain as a central psychopathological feature in the distress experienced by young adults with general psychiatric symptoms and psychological suffering; it adds evidence to the association between autistic traits and eating disorders and opens to new research questions about the role of subthreshold autistic traits in general psychopathology.

LEVEL OF EVIDENCE

Level I: Evidence obtained from experimental studies.

May Female Autism Spectrum Be Masked by Eating Disorders, Borderline Personality Disorder, or Complex PTSD Symptoms? A Case Series

Introduction: The prevalence of Autism Spectrum Disorder (ASD) is four times higher in males than females; however, females are significantly more likely to go undiagnosed due to the existence of a "female autistic phenotype", a manifestation unique to females that conflicts with conventional, masculine conceptualizations of ASD. Furthermore, subthreshold autistic traits, which exert a significantly negative impact on quality of life and represent a vulnerability factor for the development of other psychopathological conditions, may remain even more under-recognized. Subsequently, many women with ASD may never receive a diagnosis or any resulting care, with serious consequences for their health. Aims: We aimed to describe two brief cases in order to confirm the diagnostic difficulties that ASD female undergo during their clinical evaluation and the possible alternative phenotype that they can manifest. Methods: We reported the cases of two young women on the autism spectrum that came to clinical attention only after the development of severe symptomatology attributed to other mental disorders, overlooking the presence of underlying autism spectrum features and a brief résumé of the literature on this topic. Results: These cases confirm the need for a timely and proper identification of females on the autism spectrum in order to prevent complications and improve the outcome. Conclusions: Research on gender differences could lead to a reexamination of the sex ratio in the prevalence of ASD and provide a better understanding of several psychiatric conditions that are frequently diagnosed in women, supporting the neurodevelopmental approach to psychopathology.

Exploring the role of autistic traits and eating disorder psychopathology on mentalising ability in the general population

BACKGROUND

This study evaluated the role of overlapping traits and characteristics related to autism spectrum disorder (autism) and anorexia nervosa (AN) in the general population, and the impact of these traits on mentalising ability.

METHODS

A sample of young adults (N = 306), aged 18-25 years, was recruited to complete an online study that consisted of 4 measures: the Autism-Spectrum Quotient, Eating Disorder Examination Questionnaire, the Mentalization Scale, and the Reading the Mind in the Eyes task.

RESULTS

Higher levels of autistic traits, particularly difficulty with attention switching, were associated with increased eating disorder psychopathology. Overall, autistic traits and eating disorder psychopathology were related among females, but not males. Difficulty with attention switching, however, was related to eating disorder psychopathology among both females and males. Autistic traits also appear to have a greater role in mentalising ability than does eating disorder psychopathology.

CONCLUSION

The role of attention switching in overlapping traits of autism and eating disorder psychopathology needs to be more comprehensively evaluated by future research, as does the role of biological sex. Expanded knowledge in this field will help to better understand and evaluate symptoms at presentation, leading to clearer diagnoses and potentially better treatment outcomes.

Autistic traits distribution in different psychiatric conditions: A cluster analysis on the basis of the Adult Autism Subthreshold Spectrum (AdAS Spectrum) questionnaire

Increasing interest is being paid on full-threshold and sub-threshold autism spectrum conditions among adults. Sub-threshold autistic traits (AT) seem to be distributed in a continuum from the clinical to the general population, being particularly higher among subjects with other psychiatric disorders. The aim of the present study was to evaluate the distribution of AT in a sample of subjects with different psychiatric conditions by means of a cluster analysis on the basis of the score reported to the AdAS Spectrum instrument. A total of 738 subjects recruited by seven Italian Universities were divided in 5 groups depending on the clinical diagnosis: Autism spectrum disorder (ASD), subthreshold ASD symptoms (partial ASD), Bipolar disorder (BD), Feeding and eating disorders (FED), and controls (CTLs). All subjects were assessed with the AdAS Spectrum. The cluster analysis identified 3 clusters: the high, medium and low autism clusters. The Restricted interests and rumination domain reported the highest influence in forming the clusters. The high, medium and low autism clusters were respectively more represented in the ASD, partial ASD and CTL groups. The clusters were represented intermediately in the FED and BD groups, confirming the presence of intermediate levels of AT in these clinical populations.

Inaccessibility of care and inequitable conceptions of suffering: a collective response to the construction of "terminal" anorexia nervosa

Informed by our lived experiences with eating disorders, our work providing direct support to communities underserved by existing healthcare structures, and our commitment to social justice, we are deeply troubled by several aspects of the proposed characteristics for "terminal" anorexia nervosa outlined by Gaudiani et al. in Journal of Eating Disorders (10:23, 2022). We have identified two substantial areas of concern in the proposed characteristics provided by Gaudiani et al. and the subsequent publication by Yager et al. (10:123, 2022). First, the original article and the subsequent publication fail to adequately address the widespread inaccessibility of eating disorder treatment, the lack of parameters for what constitutes "high quality care", and the prevalence of trauma experienced in treatment settings for those who do access treatment. Second, the characteristics proposed for "terminal" anorexia nervosa are constructed largely based on subjective and inconsistent valuations of suffering which build on and contribute to harmful and inaccurate eating disorder stereotypes. Overall, we believe these proposed characteristics in their current form stand to detract from, rather than assist, the ability of patients and providers to make informed, compassionate, and patient-centered decisions about safety and autonomy both for individuals with enduring eating disorders and for individuals with more recently diagnosed eating disorders.

Measuring Social Camouflaging in Individuals with High Functioning Autism: A Literature Review

In the recent years, growing attention has been paid to the use of camouflaging strategies by adult populations suffering from autism spectrum disorder (ASD) with milder manifestations and without intellectual impairment, which may lead to a delay in diagnosis or even a misdiagnosis. In fact, high-functioning ASD individuals were reported to be more aware of their communication difficulties and were more likely make considerable efforts to adjust their behavior to conventional rules of non-autistic individuals, learning to imitate other non-ASD individuals. Moreover, females reported a higher frequency of camouflaging strategies, suggesting a role of camouflaging in the gender gap of the ASD diagnosis. Although camouflaging strategies can sometimes grant a better level of adjustment, even resulting in a hyper-adaptive behavior, they are also often correlated with negative mental health consequences due to the long-term stress associated with continuous attempts to adapt in day-to-day life. In this framework, the aim of the present work was to review the available studies that assessed the presence and correlates of camouflaging strategies in individuals with ASD. Although the literature available on the topic is still scarce, some interesting correlations between camouflaging and anxious and depressive symptoms, as well as suicidality, were highlighted. In particular, the controversial and sometime opposite thoughts and results about camouflaging may be clarified and integrated in light of a dimensional approach to psychopathology.

Neural processing of self-touch and other-touch in anorexia nervosa and autism spectrum condition

INTRODUCTION

The tactile sense plays a crucial role in the development and maintenance of a functional bodily self. The ability to differentiate between self- and nonself-generated touch contributes to the perception of the bodies' boundaries and more generally to self-other-distinction, both of which are thought be altered in anorexia nervosa (AN) and autism spectrum condition (AS). While it has been suggested that AN and AS are characterized by overlapping symptomatology, they might differ regarding body perception and self-other-distinction.

METHODS

Participants with a diagnosis of AN (n = 25), AS (n = 29), and a comparison group without diagnoses (n = 57) performed a self-other-touch task during functional brain imaging. In the experimental conditions, they stroked their own arm or were stroked on the arm by an experimenter.

RESULTS

As shown previously, the CG group showed lower activation or deactivation in response to self-touch compared to social touch from someone else. A main group effect was found in areas including somatosensory cortex, frontal and temporal gyri, insula, and subcortical regions. This was driven by increased activations in participants with AN, while participants in the AS group showed mostly comparable activations to the comparison group.

CONCLUSIONS

AN diagnosis was associated with an increased neural activity in response to both self-touch and social touch. Failure to attenuate self-touch might relate to altered predictions regarding the own body and reduced perception of bodily boundaries. Participants with an AS diagnosis were mostly comparable to the comparison group, potentially indicating unaltered tactile self-other-distinction.

Are the obsessive-compulsive traits a moderator for the relationship between autism and anorexia? A cross-sectional study among university students

ObjectiveIt is known that there is a high comorbidity between eating disorders and autistic traits among both the clinical and non-clinical populations. In this study, it is aimed to investigate the relationship between ASD and AN, and the effects of obsessive-compulsive traits. Participants: The study has been conducted in a non-clinical sample. A total of 290 university students have been included. Methods: Autism Quotient (AQ), Eating Attitudes Test (EAT) and Maudsley Obsessive-Compulsive Inventory (MOCI) have been used. Results: There is a positive relationship between EAT-40, MOCI scores, and AQ total scores. However, after controlling the sex and MOCI scores relation in total AQ and EAT-40 scores, they have become statistically insignificant. In regression, only MOCI scores and AQ Communication subscale scores have been able to predict the EAT-40 scores. Conclusions: It has been found that the relationship between autistic traits and eating attitudes is moderated by obsessive-compulsive traits.

Investigating the relationship between orthorexia nervosa and autistic traits in a university population

BACKGROUND

Orthorexia nervosa (ON) is an emerging condition featuring restrictive eating behaviors on the basis of subjective beliefs about food healthiness. Many authors have stressed the similarities between ON and anorexia nervosa (AN) in both cognitive and behavioral patterns. Despite that, while the link between AN and female autism presentations is well known in the literature, no study has yet investigated the relationship between ON and autism spectrum. This work aims to investigate the relationship between ON and autistic traits in a university population.

METHODS

An e-mail invitation was sent to all the students and University workers of University of Pisa. Subjects were asked to fulfill the ORTO-15 and the Adult Autism Subthreshold spectrum (AdAS spectrum) questionnaires.

RESULTS

A total of 2426 subjects joined the survey: 623 subjects (26.3%) reported a score associated with significant orthorexic symptoms according to ORTO-15 (ON group), while 1789 subjects (73.7%) did not report ON symptomatology and were considered as healthy controls (HC). The ON group scored significantly higher on almost all AdAS spectrum domains. Moreover, being female and scoring higher on AdAS spectrum were statistically predictive factors for the presence of ON symptomatology. Among AdAS spectrum domains, higher scores on AdAS spectrum inflexibility and adherence to routine and restricted interests and rumination domains, as well as lower scores on verbal communication domain, were statistically predictive of orthorexic symptoms.

CONCLUSIONS

Our findings highlight an overlap between ON and autism spectrum psychopathology. Further studies are needed to clarify the relationship between restrictive eating disorders and female autism phenotypes.

Familial aggregation of synaesthesia with autism (but not schizophrenia)

INTRODUCTION

This study determines whether there is a familial aggregation between synaesthesia and two neuropsychiatric conditions (autism and schizophrenia). METHOD We examined the prevalence of autism and schizophrenia among synaesthetes and non-synaesthetic controls, and among their first-degree relatives.

RESULTS

As predicted, autism occurred at elevated levels among synaesthetes and-we document for the first time-amongst their relatives. This was not found for schizophrenia, where a link may be expected, or in a control condition (type 1 diabetes) where we had no a priori reason to assume a link. Synaesthetes, compared to controls, were also more likely to have other synaesthetes in their family. People with three or more types of synaesthesia were more likely (compared to synaesthetes with fewer types) to have synaesthetic relatives and to report autism in themselves. People with two or more types of synaesthesia (compared to synaesthetes with only one type) were more likely to report familial autism.

CONCLUSIONS

The results suggest a shared genetic predisposition between synaesthesia and autism, and more extreme synaesthetes may tend to hail from more neurodiverse families.

Emotional dysregulation as trans-nosographic psychopathological dimension in adulthood: A systematic review

Introduction

Emotional dysregulation (ED) is characterized by inappropriate emotional reactions related to environmental or cognitive stimuli. In most recent years, increasing interest has been devoted to its definition and detection across mental disorders for its detrimental role progressively highlighted in both neurodevelopment and adult mental disorders, with implications on the severity of clinical manifestations. The aim of this systematic review was to evaluate and gather the scientific evidence about ED in adult psychiatric population to elucidate the concept of ED as trans-nosographic entity.

Methods

The electronics databases PubMed, Scopus and Web of Science was reviewed to identify studies in accordance with the PRISMA guidelines; at the end of the selection process a total of 29 studies (N = 709; N = 658; N = 1,425) was included. All studies included assessed the presence of ED symptoms, by means of a validate scale in adult (>18 years of age), in clinically diagnosed patients as well as healthy control participants.

Results

Our results suggest ED as a trans-diagnostic factor across multiple mental disorders, such as bipolar disorder, attention deficit hyperactivity disorder, autism spectrum disorder, personality disorders; a better definition of this concept could be helpful to interpret and clarify many clinical cases and improve their diagnostic and therapeutic management.

The hallmarks of autism

I suggest that the current study of autism is problematic, due to: (1) its failure to pursue a medical model of disease causation, with protocols for differential diagnoses of causes; (2) a notable incidence of unrecognized false positive diagnoses in children; (3) the conceptual equating of autism with sets of traits that have been shown to be genetically and phenotypically unrelated to one another; and (4) the expansion of use of the terms "autism" and "autism traits" to psychiatric conditions that have no substantive etiological or symptomatic overlap with autism. These problems can be alleviated by, like Kanner, considering autism as a syndrome, a constellation of traits, conceptualized as differences rather than deficits, some set of which is found in each affected individual to some degree. The original, prototypical form of autism can be delineated based on the "hallmarks" of autism: a set of core traits, originally explicated by Kanner, that defines a relatively-homogeneous group, and that connects with the larger set of autism symptoms. The hallmarks of autism provide a touchstone for research that is unambiguous, historically continuous to the present, and linked with major theories for explaining the causes and symptoms of autism. Use of the hallmarks of autism does not impact recognition and treatment of individuals with DSM diagnosed autism, or individuals with the many disorders that involve social deficits. This perspective is compatible with the research domain criteria approach to studying autism, via analyses of autism's constituent traits and the differential diagnosis of its individual-specific causes.

Shared familial risk factors between autism spectrum disorder and obesity - a register-based familial coaggregation cohort study

BACKGROUND

Meta-analyses suggest an association between autism spectrum disorder (ASD) and obesity, but the factors underlying this association remain unclear. This study investigated the association between ASD and obesity stratified on intellectual disability (ID). In addition, in order to gain insight into possible shared etiological factors, the potential role of shared familial liability was examined.

METHOD

We studied a cohort of 3,141,696 individuals by linking several Swedish nationwide registers. We identified 35,461 individuals with ASD and 61,784 individuals with obesity. Logistic regression models were used to estimate the association between ASD and obesity separately by ID and sex and by adjusting for parental education, psychiatric comorbidity, and psychotropic medication. Potential shared familial etiologic factors were examined by comparing the risk of obesity in full siblings, maternal and paternal half-siblings, and full- and half-cousins of individuals with ASD to the risk of obesity in relatives of individuals without ASD.

RESULTS

Individuals with ASD + ID (OR = 3.76 [95% CI, 3.38-4.19]) and ASD-ID (OR = 3.40 [95% CI, 3.23-3.58]) had an increased risk for obesity compared with individuals without ASD. The associations remained statistically significant when adjusting for parental education, psychiatric comorbidity, and medication. Sex-stratified analyses indicated a higher relative risk for males compared with females, with statistically significant interaction effects for ASD-ID, but not for ASD+ID in the fully adjusted model. First-degree relatives of individuals with ASD+ID and ASD-ID had an increased risk of obesity compared with first-degree relatives of individuals without ASD. The obesity risk was similar in second-degree relatives of individuals with ASD+ID but was lower for and ASD-ID. Full cousins of individuals with ASD+ID had a higher risk compared with half-cousins of individuals with ASD+ID). A similar difference in the obesity risk between full cousins and half-cousins was observed for ASD-ID.

CONCLUSIONS

Individuals with ASD and their relatives are at increased risk for obesity. The risk might be somewhat higher for males than females. This warrants further studies examining potential common pleiotropic genetic factors and shared family-wide environmental factors for ASD and obesity. Such research might aid in identifying specific risks and underlying mechanisms in common between ASD and obesity.

Eating disorders and autism spectrum: links and risks

In the last decades, increasing attention has been provided to socio-cultural and neurobiological factors involved in the psychopathology of feeding and eating disorders (FED), encouraging a multifactorial approach. In this framework, several authors stressed an association between FED and other kinds of psychiatric disorders from both a psychopathological and a neurobiological point of view. In particular, many promising contributions are focusing on the possible link between FED and autism spectrum disorder (ASD). Growing interest about this association rose from the frequently reported evidence of ASD-like traits amongst FED patients and abnormal eating behaviors amongst patients with ASD. This narrative review overview aims to summarize the most relevant findings about the overlap between different kinds of FED and the autism spectrum, taking into account the most recent hypotheses about the psychopathology of both these conditions. While most of the studies focused on anorexia nervosa, both ASD and autistic traits seem to be detectable also in other kinds of FED. In addition, the recently increased interest toward a dimensional approach to psychopathology led to progressively broadening the concept of ASD, focusing on its subthreshold and gender-specific manifestations and on its link with other psychiatric conditions, including FED. Globally the studies summarized here provide further support to theoretical models featuring a neurodevelopmental approach for mental disorders. In particular, FED have been conceptualized as a possible psychopathological trajectory of a neurodevelopmental alteration, toward which female gender would act as one of many predisposing factors.

Eating disturbances in eating disorders and in high-functioning autism spectrum disorders: a preliminary study

PURPOSE

The relationship between autism spectrum disorders (ASDs) and eating disorders (EDs) has been widely studied in the last decades. We aimed to directly compare patients with EDs, individuals with high-functioning ASDs (HF-ASDs) and healthy controls (HC) at measures detecting: (1) symptoms of eating disorders, (2) eating disturbances known to be characteristic of autism.

METHODS

Thirty-four patients with EDs, 34 individuals with HF-ASDs and 35 HC, all females, completed the eating attitude test (EAT-26) and the Swedish eating assessment for autism spectrum disorders (SWEAA), two self-report questionnaires assessing, respectively, symptoms and concerns characteristic of eating disorders and ASD-related eating disturbances.

RESULTS

At the EAT-26, patients with EDs scored significantly higher than individuals with HF-ASDs, and both of them scored higher than HC (p < 0.05, η_p² = 0.283). Conversely, at the SWEAA, no differences between individuals with HF-ASDs and patients with EDs emerged (p = 901), but they both scored higher than HC (p < 0.05, η_p² = 0.247).

CONCLUSION

Individuals with HF-ASDs did not seem to reach the same level of EDs symptomatology as patients with EDs. Patients with EDs did not seem to present a different amount of autistic-eating behaviours than subjects with HF-ASDs. Patients with EDs and individuals with HF-ASDs scored higher than HC at both scales. Our results give further preliminary evidence of the overlap between autistic traits and EDs symptomatology, and should be taken into account in the definition of a shared model between EDs and ASDs.

LEVEL OF EVIDENCE

Level II; Evidence obtained from controlled trial without randomization.

The role of interoception in the overlap between eating disorders and autism: Methodological considerations

Significant comorbidity has been demonstrated between feeding and eating disorders and autism. Atypical interoception (perception of bodily signals) may, at least in part, be responsible for this association, as it has been implicated in the aetiology of both conditions. However, significant methodological limitations are impeding progress in this area. This paper provides a brief overview of how interoception has been linked to autism and feeding and eating disorders in both adolescent and adult populations before identifying several issues with current measures of interoception. We suggest that methodological issues may be contributing to the inconsistency in the empirical literature, and provide suggestions for future research.

Atypical interoception is linked to both feeding and eating disorders, and autism and may contribute to the comorbidity between the two.

Existing measures of interoception across cardiac, gastric and respiratory domains are severely limited.

Novel and better‐validated measures of interoception will allow us to better understand the clinical potential of interoceptive training.

Investigating Orthorexia Nervosa With the ORTO-R in a Sample of University Students With or Without Subthreshold Autism Spectrum: Focus on Dietary Habits and Gender Differences

BACKGROUND

The aim of the present study was to investigate the presence of Orthorexia (ON) symptoms in a sample of University students with or without autistic traits (AT), specifically focusing on evaluating the role of gender and of dietary habits in the association between ON and autism spectrum.

METHODS

Subjects were requested to anonymously fill out the questionnaires through an online form.

RESULTS

Two thousand one hundred forty students participated in the study. Subjects with significant AT, measured by means of the Adult Autism Sub-threshold spectrum (AdAS Spectrum) reported significantly higher ON symptoms, as measured by ORTO-R scores, than subjects with low AT. Females and subjects following a vegetarian/vegan diet reported significantly higher ORTO-R scores than males and than subjects following an omnivorous diet, respectively. Significant positive correlations were found between ORTO-R and AdAS Spectrum scores. A decision tree model, with gender, type of diet and presence of high AT as independent variables and ORTO-R score as dependent variable, showed in the first step the presence of significantly higher ORTO-R scores among females than among males, and in the second step showed in both genders the presence of higher ORTO-R scores among subjects with high AT than in those with low AT. A significant interaction of gender and presence/absence of high AT was reported on ORTO-R score, with a higher increasing trend of ORTO-R score with the increase of AdAS Spectrum score among females than among males.

CONCLUSIONS

Our results further highlighted the association between AT and ON, in particular among females.

How to support adults with anorexia nervosa and autism: Qualitative study of clinical pathway case series

INTRODUCTION

Previous research has explored the overlapping presentation between autism and eating disorders (ED). This study aims to summarize the clinical challenges associated with co-occurring autism and anorexia nervosa (AN) based on clinicians' case notes and minutes from case discussions, to understand how to better support people with the comorbidity.

METHOD

Thematic analysis was conducted on de-identified notes on 20 cases with AN and autistic characteristics and minutes from case discussions. Themes relevant to clinical challenges in supporting those with the comorbidity were identified, and a thematic map was produced to visually represent the results.

RESULTS

The key challenges faced by clinicians when treating patients with AN and autism included: communication difficulties, maintaining boundaries, autism screening, presence of other comorbidities, sensory difficulties, atypical presentation of eating difficulties, cognitive rigidity, and emotional difficulties. Adaptations to resolve some of these difficulties included exposure-based food experiments, keeping a record of patients' self-reported communication preferences, individual-level modification of communication style, and providing tools for patients to identify emotions.

CONCLUSIONS AND IMPLICATIONS

Further exploration to establish the effectiveness of the adaptations is warranted. Furthermore, tools for differentiating between ED, autism and other comorbidities are needed to help clinicians clarify the cause of a presenting symptom, and help them to best support and maintain boundaries with patients.

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.

Diethylstilbestrol and autism

It is acknowledged that diethylstilbestrol (DES), a synthetic diphenol with powerful estrogenic properties, causes structural anomalies of the reproductive tract and increases the risk of cancer and genital malformations in children and grandchildren of mothers treated during pregnancy. Conversely, data on DES effects on neurodevelopment and psychiatric disorders in in-utero exposed children and their descendants are rare, especially concerning Autism Spectrum Disorders (ASD). Recent studies presented in this review strengthen the hypothesis that in-utero exposure to DES and also other synthetic estrogens and progestogens, which all are endocrine disruptors, contributes to the pathogenesis of psychiatric disorders, especially ASD. A large epidemiological study in the USA in 2010 reported severe depression in in-utero exposed children (n=1,612), and a French cohort study (n=1,002 in-utero DES exposed children) in 2016 found mainly bipolar disorders, schizophrenia, major depression, suicide attempts, and suicide. Few publications described ASD in in-utero exposed children, mainly a Danish cohort study and a large Chinese epidemiological study. Molecular studies on endocrine disruptors demonstrated the transgenerational induction of diseases and DES epigenetic impact (DNA methylation changes) at two genes implicated in neurodevelopment (ZFP57 and ADAM TS9). We recently described in an informative family, somatic and psychiatric disorders in four generations, particularly ASD in boys of the third and fourth generation. These data show that the principle of precaution must be retained for the protection of future generations: women (pregnant or not) should be extremely vigilant about synthetic hormones.

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.

Autistic Traits and Social Responsiveness: The Relationship Between Autistic Traits and Comorbid Psychiatric Symptoms in Adolescents with Anorexia Nervosa

INTRODUCTION

It is known that patients with anorexia nervosa (AN) display social difficulties like social responsiveness and high levels of autistic behaviors such as rigidity, narrow interests of food and weight; however it is not clear whether they have comorbid Autism Spectrum Disorders (ASD) or it is about acute phase of illness. In this study it is aimed to investigate autistic traits and social responsiveness in adolescents with AN.

METHODS

Study group was consisted of 39 female AN patients aged between 12-18 years. Control group was consisted of 34 female adolescents who did not have any psychiatric disorder. K-SADS-PL was applied to all participants in order to detect the psychiatric disorders. Autism traits and social responsiveness were evaluated using Social Responsiveness Scale. All adolescents of the study were administered The Eating Attitude Test, Beck Depression Inventory, Screen for Child Anxiety and Related Disorders, Maudsley Obsesive Compulsive Inventory.

RESULTS

Results of the study indicated that adolescents with AN had higher symptoms of depression, anxiety and autism-like symptom clusters; and lower social responsiveness. Psychiatric comorbidities were not associated with these difficulties.

CONCLUSION

The results show that AN patients have an impairment of social responsiveness, the impairment seems to be associated with AN regardless of psychiatric comorbidities. Despite these two disorders are considered unrelated, they have several traits in common. These results suggest that there may be a common pathogenesis between ASD and AN.

The Mental and Physical Health Profiles of Older Adults Who Endorse Elevated Autistic Traits

OBJECTIVES

The mental and physical health profile of autistic people has been studied in adolescence and adulthood, with elevated rates of most conditions being reported. However, this has been little studied taking a dimensional approach to autistic traits and in older age.

METHODS

A total of 20,220 adults aged 50-81 years from the PROTECT study reported whether they experienced persistent sociocommunicative traits characteristic of autism. Approximately 1%, 276 individuals, were identified as endorsing elevated autistic traits in childhood and currently, henceforth the "Autism Spectrum Trait" (AST) group. An age- and gender-matched comparison group was formed of 10,495 individuals who did not endorse any autistic behavioral traits, henceforth the "Control Older Adults" (COA) group. Differences between AST and COA groups were explored in self-reported psychiatric diagnoses, self-reported symptoms of current depression and anxiety, and self-reported physical health diagnoses. Associations were also examined between autistic traits and health across the whole sample.

RESULTS

The AST group reported significantly elevated rates of psychiatric diagnoses compared to the COA group. Additionally, the AST group showed significantly higher self-reported symptoms of current depression and anxiety than the COA group. However, few differences were observed in individual physical health conditions, and no differences in total co-occurring physical diagnoses between groups. Similar associations between autistic traits and health were also found taking a dimensional approach across the whole sample.

DISCUSSION

These findings suggest that older adults with elevated autistic traits may be at greater risk of poorer mental, but not physical, health in later life. Future studies should incorporate polygenic scores to elucidate the possible genetic links between the propensity to autism/high autistic traits and to psychiatric conditions, and to explore whether those with elevated autistic traits experience particular barriers to mental health care.

The Effectiveness of RAADS-R as a Screening Tool for Adult ASD Populations

Adult referrals to specialist autism spectrum disorder diagnostic services have increased in recent years, placing strain on existing services. It was proposed that the Ritvo Autism Asperger's Diagnostic Scale could be used as a screening tool, in order to identify and prioritise patients most likely to receive an ASD diagnosis. This study evaluates the validity of the RAADS-R as a screening tool for ASD in an adult population. Retrospective case note analysis was used to evaluate the efficacy of the RAADS-R as a screening tool to predict ASD diagnostic outcomes in 50 service users of a NHS specialist autism service. Results indicate no association between RAADS-R scores and clinical diagnostic outcome, suggesting the RAADS-R is not an effective screening tool for identifying service users most likely to receive an ASD diagnosis. In conclusion, used as a self-report measure pre-full diagnostic assessment, the RAADS-R lacks predictive validity and is not a suitable screening tool for adults awaiting autism assessments. Future research should aim to identify reliable screening tools for this purpose.

AAA screening in adults with ASD: a retrospective cohort study

Purpose

The Adult Asperger Assessment (AAA), comprising the Autism Questionnaire, the Empathy Quiotient and the Relatives Questionnaire is a commonly used screening tool designed to identify adults who may benefit from a further clinical assessment for autism spectrum disorder. The purpose of this paper is to investigate the usefulness of this screening measure in a clinical setting.

Design/methodology/approach

This retrospective cohort study comprised of 192 service users referred for diagnostic assessment of Autism by a specialist service of the National Health Service. The authors evaluated the diagnostic accuracy of the AAA by investigating if the Autism Questionnaire, the Empathy Quiotient and the Relatives Questionnaire were able to predict the diagnostic outcome of Autism in a clinical setting.

Findings

Scores from the Relatives Questionnaire can accurately predict diagnostic outcome. No evidence of accuracy for the Autism Questionnaire or the Empathy Quotient was apparent. Based on the findings, the authors recommend clinicians are cautious when interpreting results of the AAA.

Research limitations/implications

It should be acknowledged that the results may not be generalisable to whole populations. Also, the authors used the full item versions of the scales; therefore, the findings are most applicable to studies which did similar.

Originality/value

This study highlights the need for investigation into the lack of validation of commonly used screening measures in autistic populations.

Adolescents With Autism Spectrum Disorder and Anorexia Nervosa Comorbidity: Common Features and Treatment Possibilities With Cognitive Remediation Therapy and Oxytocin

Autistic traits or autism spectrum disorder (ASD) can be found in 4% to 52% of anorexic patients, which makes the treatment of these patients very challenging. In this review, possible ways to treat ASD and anorexia nervosa (AN) comorbidity in children and adolescents are summarized. Over recent years, the focus has shifted from searching for the evidence of connections between these two disorders, which have started with Gillberg's study in 1983, to searching for more effective and holistic treatment of this comorbidity. The latter is known to contribute to more severe courses and worse prognosis, which is probably related to the obstacles in both diagnosing and treating. Since AN usually starts in early adolescence and high-functioning ASD children seem to begin struggling with increased pressure in adolescence, while various comorbidities can occur, it is important to improve the treatment of this comorbidity in young patients and to tailor it specifically in terms of diagnosing. In this paper, a literature review is conducted on common features and promising treatment possibilities. We describe cognitive remediation therapy and the promising pharmacotherapeutic candidate oxytocin with a special focus on adolescents.

Gender Differences in Misdiagnosis and Delayed Diagnosis among Adults with Autism Spectrum Disorder with No Language or Intellectual Disability

Autism Spectrum Disorder (ASD) is often unrecognized, especially in mild forms and in women. Studies evaluating features associated with missed/misdiagnosis in men and women with ASD are warranted. 61 subjects (22 females, 39 males, age 28.5 ± 10.8 years) with ASD with no language/intellectual deficit were enrolled in the service for the treatment of psychiatric comorbidities in adults with ASD of the ASST Fatebenefratelli-Sacco in Milan (Italy). A detailed clinical history was gathered, and two self-report questionnaires (Autism Spectrum Quotient-AQ and Adult Autism Subthreshold Spectrum-AdAS Spectrum) were administered. 75.4% received their ASD diagnosis average eight years later than the first evaluation by mental health services. Compared to males, females showed a significantly greater delay in referral to mental health services and a significantly higher age at diagnosis of ASD. Among men, diagnostic delay inversely correlated with scores on the AdAS Spectrum total, Verbal communication, Empathy and Inflexibility and adherence to routine domains. Among women, diagnostic delay positively correlated with the Attention to detail score while the age at diagnosis of ASD positively correlated with the AdAS Spectrum Verbal communication and Restricted interests and rumination domain scores. Females were less likely to be correctly diagnosed and more likely to be misdiagnosed at first evaluation than men. Females reported significantly higher scores than men in the Hyper/Hyporeactivity to sensory input domain only among subjects who were misdiagnosed. Our findings provide gender-specific information about ASD patients seeking help for comorbid conditions and might be a primary ground for future research.

The Association Between Autistic Traits and Disordered Eating is Moderated by Sex/Gender and Independent of Anxiety and Depression

Previous studies have reported positive correlations between autistic traits and disordered eating, though it is unclear whether the association is moderated by sex/gender or whether it is independent of anxiety or depression. We present the findings of an online survey of 691 participants who completed the Autism Spectrum Quotient (AQ), Hospital Anxiety and Depression Scale (HADS), and Eating Attitudes Test-26 (EAT-26). Following a pre-registered analysis plan, we observed positive correlations between AQ and EAT-26 in males and females, with the association being significantly stronger in females. AQ also remained a significant predictor of EAT-26 when anxiety and depression were controlled for statistically. These findings may be relevant when considering therapeutic interventions in disordered eating populations that exhibit autistic traits.

'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.

A road map for identifying autism spectrum disorder: recognizing and evaluating characteristics that should raise red or "pink" flags to guide accurate differential diagnosis

Objective: Given the high population prevalence of Autism Spectrum Disorder (ASD) and overlapping symptoms with medically complex groups, ASD is a common rule out diagnosis for neuropsychologists even when not identified in the referral or initial presenting concerns. This paper presents practical guidance to support neuropsychologists in their ability to accurately assess, diagnose, and/or rule out ASD, especially in patients with more subtle presentations. Method: This paper combines clinical experience and empirical literature to highlight important assessment measures and related considerations, differential diagnostic considerations, common misconceptions about ASD and person/family characteristics, as well as variability in presentation and comorbidities that can obscure the diagnosis. Characteristics that may be considered "red flags" (clearly diagnostic, classic symptoms) and "pink flags" (associated features and symptoms that are suggestive of ASD but not quite definitive and that may overlap with symptoms seen in other neurodevelopmental or psychiatric diagnoses) will be discussed. Conclusions: Neuropsychologists in all clinical settings should be able to effectively screen for and/or diagnose ASD, even when its presentation is more subtle and/or when symptoms are masked by patient strengths in a way that makes their clinical presentation less obvious. Practical strategies for communicating the diagnosis and next steps/recommendations for interventions are reviewed.

Prevalence of autism spectrum disorder and autistic traits in children with anorexia nervosa and avoidant/restrictive food intake disorder

BACKGROUND

Autism spectrum disorder (ASD) and feeding and eating disorders (FEDs) such as anorexia nervosa (AN) are strongly linked as evidenced by frequent comorbidity and overlapping traits. However, eating and social behaviors are shaped by culture, so it is critical to examine these associations in different populations. Moreover, FEDs are heterogeneous, and there has been no examination of autistic traits in avoidant/restrictive food intake disorder (ARFID).

METHODS

Therefore, we investigated the prevalence of ASD and autistic traits among Japanese children with AN (n = 92) or ARFID (n = 32) from a prospective multicenter cohort study using the Autism Spectrum Quotient Children's version (AQC) and Children's Eating Attitudes Test (ChEAT26).

RESULTS

ASD prevalence was high in both AN and ARFID (16.3 and 12.5%, respectively). The AN group exhibited significantly higher scores on all AQC subscales than an age-matched healthy control (HC) group, but there were no significant correlations between AQC scores and ChEAT26 scores. In the AFRID group, AQC scores did not differ from HCs, but significant correlations were found between total AQC and ChEAT26 scores and between several AQC and ChEAT26 subscales.

CONCLUSIONS

Both the AN and ARFID groups had high prevalence rates of ASD. The AN group showed a significantly higher degree of autistic traits than the HC group; however, no difference was found between the ARFID and HC groups. Clinicians need to be aware of these rates when working with children with ED.

Eating disturbances in adults with autism spectrum disorder without intellectual disabilities

There is a growing interest in the relationship between autism spectrum disorders (ASDs) and eating disorders (EDs), two relatively common conditions lying on a spectrum from mild to severe clinical features. However, only limited data are available about pathological eating behaviors throughout adults on the autistic spectrum. The aim of the present study is to assess dysfunctional eating behaviors, including EDs manifestations and ASDs-related eating disturbances, in a population of adults with ASDs without intellectual disabilities. We recruited 106 adults on the autistic spectrum, without intellectual disability and 103 neurotypical adults (NAs). Participants completed the "Eating Attitude Test" (EAT-26), to measure symptoms and concerns characteristic of EDs, and the "Swedish Eating Assessment for Autism Spectrum Disorders" (SWEAA), to assess eating behaviors frequently observed within the autistic spectrum. Participants with ASDs scored significantly higher than NA at the EAT-26 and at the SWEAA. Moreover, participants with ASDs scored higher than NA at the EAT-26 subscales Dieting and Bulimia. The difference between groups remained significant after controlling for the effect of age, biological sex, and BMI. These results suggest that adults with ASDs without intellectual disability presented not only a higher prevalence of eating disturbances typical of the autistic spectrum, but also other symptoms of EDs in comparison to NA. LAY SUMMARY: For both scales assessing eating disturbances (EAT-26 and SWEAA), participants with ASDs scored higher than NA, presenting a higher prevalence both of eating disturbances typical of ASDs and of ED symptoms (distorted body image, tendency toward bulimic behaviors, and self-control of eating).

Autism spectrum disorder and anorexia nervosa: an Italian prospective study

BACKGROUND

Potential overlaps exist between psychopathological features of Anorexia Nervosa (AN) and Autism Spectrum Disorder (ASD). The impact of malnutrition on autistic traits in patients with AN should be considered. This study investigates possible associations among the psychopathology of Eating Disorders (EDs), ASD traits and BMI in a group of young patients with AN, using the EDI-3 (Eating Disorder Inventory-3) test and gold-standard measures for ASD.

METHODS

Prospective study involving 23 inpatients admitted to an Italian Centre for paediatric ED. ASD traits and ED psychopathology were assessed administering the ADOS-2 (Autism Diagnostic Observation Schedule-2), AQ (Autism Quotient) and EDI-3 tests. Both present and past autistic traits were investigated using different versions of AQ. Correlations were adjusted for BMI, Obsessive Compulsive Disorder (OCD) comorbidity and concurrent antipsychotic treatments.

RESULTS

An ASD diagnosis was possible in 22% of patients. Significant correlations were documented between ASD traits and ED psychopathology: AQ total-Interpersonal problems (IPC) (p = 0.041); AQ total-Global psychological maladjustment (GMPC) (p = 0.027); AQ social skills-Ineffectiveness (IC) (p = 0.018); AQ social skills-IPC (p = 0.019); AQ social skills-Affective problems (APC) (p = 0.025); AQ social skills-GMPC (p = 0.007); AQ attention switching-IPC (p = 0.020); ADOS-2 imagination-IC (p = 0.035). These correlations were independent of BMI, OCD and antipsychotic treatments.

CONCLUSIONS

ASD traits presented high prevalence in a group of young inpatients with AN. These traits were significantly correlated to 4 specific EDI-3 subscales and independent of BMI. This is the first study to investigate the relationship between ASD traits as measured with gold-standard measures, EDI-3 scores, and BMI.

Anorexia nervosa and autism: a prospective twin cohort study

BACKGROUND

Anorexia nervosa (AN) and autism spectrum disorder (ASD) may be phenotypically and etiologically linked. However, due to the absence of prospective studies, it remains unclear whether the elevation of autistic traits in AN is evident in early childhood. Here, we prospectively investigated autistic traits before and after the first diagnosis of AN.

METHODS

In a population-based sample of 5,987 individuals (52.4% female) from the Child and Adolescent Twin Study in Sweden, parents reported autistic traits at ages 9 and 18. AN and ASD diagnoses were retrieved from the Swedish National Patient Register. In addition, AN diagnoses were ascertained by parent-reported treatment for AN. We compared whether individuals with and without AN differed in autistic traits before the first diagnosis of AN (age 9) and after the first diagnosis of AN (age 18).

RESULTS

We did not find evidence for elevated autistic traits in 9-year-old children later diagnosed with AN. At age 18, however, there was a marked elevation in restricted/repetitive behavior and interests, but only in the subgroup of individuals with acute AN. A less pronounced elevation was observed for social communication problems.

CONCLUSIONS

Coping strategies in individuals with ASD and the somewhat different female ASD phenotype may explain why we did not find elevated autistic traits in children who later developed AN. Alternatively, it is possible that elevated autistic traits were not present prior to the onset of AN, thus questioning the previously reported elevated prevalence of ASD in AN. Future studies should use tailored measurements in order to investigate whether autistic traits in individuals with AN are best conceptualized as an epiphenomenon of the acute AN phase or whether these symptoms indeed represent ASD as a clinically verifiable neurodevelopmental disorder.