Anorexia as an autism spectrum disorder?

After writing my blog earlier this week about Asperger’s Syndrome, I was intrigued when I opened my newly delivered copy of the European Eating Disorders Review journal on Thursday (Vol. 19, Issue 6, Nov-Dec 2011) to see the first article entitled; “Is anorexia nervosa a version of autism spectrum disorders?”  The research essentially highlights similarities in cognitive functioning between people diagnosed with anorexia and those with an autism spectrum disorder.

Reading this article has led me to see what other research I could find about this link so I could think about the possibility for myself.  My earlier blog was inspired by my thinking about someone close to me and my struggle to understand them.  This new angle has now made me revisit some of my understandings about myself; as someone who was once diagnosed with anorexia.  In my earlier blog, I noted that I saw some traits of Asperger’s within myself … where does this new information leave me with my understanding of myself?  And of my relationship with this other person?

There isn’t a great deal of research to be easily found, but what I have found, I’ve written about, under the heading of ‘So what has the research out there told me?’ below.  For people not interested in reading the details of the research or my reactions to it, I’ve written ‘My Own Thoughts’ on the possible link immediately below …

My Own Thoughts

Reading the research was initially another ‘light bulb’ moment of enlightenment for me.  I thought; “Yes, I can see the links; makes a lot of sense to me!”  Anorexia definitely shares some of its traits with autism spectrum disorders, and more specifically the Asperger’s end of the spectrum (see bullet-point list below for comparative examples).  When I was ‘anorexic’ I would have satisfied a lot of the Asperger’s traits to quite a high degree … as would most anorexics.  Strange to think that at that time, I could probably have satisfied an Asperger’s diagnosis … and yet, that definitely wasn’t my experience; I was Anorexic.

And now, no longer anorexic, I can still see my tendency towards those traits (as I’m sure many people who haven’t experienced eating difficulties can!) but my increased self-acceptance and self awareness enable me to use those traits in a constructive and life-enhancing way.  With anorexia, there is a way forward … helping the individual work through their need to control food and / or their body and enabling them to gain weight.  The physiological effects of starvation create and / or exacerbate these same traits, so someone with anorexia whose weight drops significantly will display them, but once their weight rises out of the ‘danger zone’ the traits diminish.   The individual with a diagnosis on the autism spectrum disorder does not ‘recover’ … they might learn ways of managing their life effectively to compensate for their autistic / aspergic traits, but they can’t recover in the same way as many people with anorexia can, and do.

Seeing the similarities, has helped me understand how easily I related to, & connected so deeply with, someone in my life with Asperger’s … I was seeing parts of myself there.  I could understand that other person’s way of thinking, their way of being in the world … because I’d been there myself.  And although I’m no longer there to a significant extent, I do still have the understanding I gathered as a result of my time spent in that anorexic-aspergic world, making it so much easier for me to effectively relate to, and with, someone with Asperger’s.

If there are links between anorexia and autism spectrum disorders, it opens a lot of questions as to how we currently help people with anorexia.  Most treatment currently focuses on challenging the anorexic thinking and behaviour, exploring reasons behind the behaviour to find what purpose it serves for the individual and either resolving those underlying issues or helping them find more effective coping strategies, and exploring their relationship with food and their bodies to encourage a healthier way of relating.  However, if it was the case that anorexia had a neurobiological component, like autism spectrum disorders, therapy wouldn’t improve the condition to any significant degree.

And like myself, many people who have been anorexic move into Bulimia, which encompasses many different personality traits.  The individual with bulimia loses some of their perfectionism, their ability to maintain control or to focus on the minutia.  They often feel at the mercy of their emotions whereas anorexics and those on the autism spectrum are less able to experience or recognise such swings in emotion.

I’m not sure … there may be links, but I’d like to see some more definitive research before I wholeheartedly endorse the idea.  Yes, I think the two ‘conditions’ display a number of similarities, but I’m not convinced they’re part of the same ‘disorder’ … I’d be happy to be proved wrong though!  

The research does seem to indicate a higher than normal prevalence of autism spectrum disorders within diagnosed anorexics than in the general population, but for me, this doesn’t prove the link.  Instead it makes sense to me that females on the  autism spectrum (diagnosed or not), because of the cultural imperative to be thin in modern Western society and hence control eating and body weight / shape, are probably more likely to turn to anorexic behaviour as a coping mechanism.

As someone currently working with people with anorexia, and with a past anorexic diagnosis, I think the recognition of these links is important in that it has helped me gain yet again, a deeper understanding of Anorexia and also of Asperger’s, which can only be a good thing…

So what has the research out there told me?

In previous research in 2007, Professor Janet Treasure (professor of psychiatry at the Institute of Psychiatry, King’s College, London, and a recognised ‘authority’ on eating disorders) suggested two aspects of the link between anorexia and autistic spectrum traits.  The first is that because of their propensity for black and white thinking, needing to feel in control and an obsession with rules and systematic thinking, girls on the autism spectrum are more likely to be drawn into the controlled world of anorexia.  Having rules to follow around eating affords them the safety and control they enjoy.  The second link comes from the physiological changes brought about as a result of the effects of starvation on the body, which echo and exaggerate the autistic traits.  The effects of starvation on the brain include impaired cognitive functioning, a tendency to think in black and white terms, a focus on themselves and an increasing difficulty in reading other people … all common traits of those on the autism spectrum.

There seems to be a higher prevalence of autism spectrum disorder in those diagnosed with Anorexia Nervosa than in the general public; a study reported by Janet Treasure in 2007 claimed 1 in 5 anorexics met the criteria for an autism spectrum disorder and Tony Atwood (a recognised ‘expert’ on Asperger’s), also in 2007, reported between 18% & 23% of anorexic teenage girls meeting some or all of the criteria for Asperger’s Syndrome.  The prevalence rate for all autistic spectrum disorders in the general population is estimated to be around 1%.  For me, as written above, this simply indicates that females with an autism spectrum disorder are more likely than the general population to use anorexia as a way of attempting to deal with their personality traits.  Or that girls who develop anorexia typically share many of the autism spectrum disorder traits and their anorexic behaviour and physiological changes it brings about exacerbates these same traits.

One area in which Janet Treasure links anorexia with autism spectrum disorders is from a neurobiological basis.  It has been established that autism spectrum disorders result from atypical neurological processing (the brain processing information in a different way from the person not on the autism spectrum) and Treasure has proposed that anorexia results in part from this neurobiological level.  This is an interesting concept as it impacts on the current understanding of eating disorders being more socio-culturally influenced.  It consequently has huge implications for how we work with people presenting with anorexia.  There appears to be, as yet, no definitive research to confirm or disprove this theory.

For myself, the following similarities when they were first highlighted to me were what excited me and made me think that maybe a link between the two ‘conditions could be possible. Common symptoms shared between people with a diagnosis of anorexia and those on the autism spectrum include…

• Obsessive or compulsive behaviour
• A tendency towards perfectionism with the individual having a need to do things perfectly or completely
• Reduced ability to see, and think about, self-identity and connections with others
• Difficult empathising
• A tendency towards focusing on minute details, and therefore, an inability to see the bigger picture 
• Difficulty with multi-tasking or switching between ideas and tasks
• A lack of flexibility in their thinking, which makes coping with changes in plans or routines very difficult and stressful
• A like of routine
• Difficulty in negotiating, and coping with, life changes
• Ritualised eating, food preparation, or exercise routines
• Increased incidence of anxiety and depression

However, as discussed above, people diagnosed with anorexia are able to move away from these rigid patterns as they ‘recover’ … unlike those with an autism spectrum diagnosis … unless, the individual experiencing anorexia actually has a co-morbid autism spectrum diagnosis.

Another similarity which intrigued me, because I wasn’t aware of it, and which again, highlights a physiological element to anorexia is that both individuals diagnosed with anorexia and those on the autism spectrum have lower levels of Oxytocin. Oxytocin is a hormone involved in social recognition, the ability to empathise, bonding and sexual arousal; all of which may be impaired in these two categories of people. 

Anorexia has been called the female Asperger’s … Professor Christopher Gillberg, writing in 2005 suggested that autism spectrum disorders may be overlooked in girls as they present in different ways than with males; for example, anorexia, and it may be easy to overlook the possibility of an autism spectrum diagnosis when the presenting symptoms are indicating anorexia.  As I wrote above, for me it seems likely that females on the  autism spectrum (diagnosed or not), because of the cultural imperative to be thin in modern Western society and hence control eating and body weight / shape, are probably more likely to turn to anorexic behaviour as a coping mechanism.

I’m always happy to have my current ways of thinking challenged (doesn’t that statement itself ‘prove’ how far I’ve moved away from an anorexic / aspergic way of thinking!?!) and for me, challenging my beliefs, allows me to question them and to look around them and decide if I really do still believe them as they stand.  It allows me to adapt and expand my understandings and ways of thinking about things and to see a bigger picture as more relevant research emerges. I suspect that this will be an area of research I keep a close eye on …