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Anorexia Nervosa and Autism

12/6/2011

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A post in Autism Key discusses the links between autism and anorexia nervosa.  It reminded me of a presentation by the wonderful Professor Janet Treasure given to the Eating Disorders Breakfast meeting in Sydney last year.  (These breakfast meeting are hosted by my friends at The Centre for Eating and Dieting Disorders and also by The Australia and New Zealand Academy of Eating Disorders).  The presentation goes for about an hour and half (and is worth watching), but I thought I would summarise some of the main points.

The initial description of autism and anorexia was described in the early 1980's by Chris Gilbert.  The research was ignored largely in the ED international community.  He found about a 20% of patients with AN fit with autism spectrum disorders (ASD). The group makes criteria prior to the development of AN. In an inpatient unit this comorbidity of ASD and AN has been found to be around 50% in one study (which seems high from my experience).  Patients with ASD tend to do less well in our traditional treatment models.

Patients with ASD show three typical cognitive patterns. First, the demonstrate what is described as poor "theory of mind", which means they have difficulty in reading other peoples emotional cues, and how to behave socially.  The best article I have read on this that helped me understand this was this one.
Second, people with ASD demonstrate cognitive rigidity with a high focused on detail, which is often referred to as weak central coherence. Third, ASD patients have great difficult with what we call set shifting, which means flexibility.

We know from the work of Janet's group that patients with AN also show difficulties with cognitive rigidity and a focus on detail. They cant see the trees for the wood.  The brain seems to be wired that way. They learn very detailed rules about eating and dieting.  With starvation, this rigidity and rule adherence accentuates.  The focus on detail (weight and shape) make it difficult to see the bigger picture (the global values that we hold).  The difficulty with set shifting means that once these rules are in place patients with AN find it very difficult to take a step back and see the bigger picture (such as the consequences of their behaviour).  What is great about this neurological research is that it helps us understand  that the behaviour that we see in AN is a product of biologcally based thinking patterns.  This does not mean that these are unchangable (think neuroplasticity), but it does mean that the behaviours in a pateint with AN is not simply willful refusal to eat, they are the product of biologically mediated patterns of thinking.  The short point here is that the behaviour is not the patients fault.  As Professor Treasure points out, these patterns are all made worse by starvation, which is why this needs to be a central part of treatment.

What helps me understand the possible links between ASD and AN more is the work on emotion regulation and social engagement in AN.  Treasure talks of an increased sensitivity to "punishment" or negative affect.  This includes avoidance of negative emotions and an increased sensitivity to negative facial expressions.  This is worse in states of acute illness and less so when weight is recovered, but the traits may be there in childhood.  Interestingly, as the focus is on threat and negativity, these negative cues are processed preferentially to positive cues.  This may be an explanation for the exaggerated social negativity bias and sense of poor self worth in patients with anorexia.  To me this highlights the importance of a therapy which helps patients attune to and preferentially "take in the good" to combat the negativity bias.  I would suspect an increasing focus on Compassion Focused Therapy may be present in future years.  In discussing therapy implication Janet Treasure discusses acceptance and mindfulness approaches.

As with most things in eating disorders, Treasure argues that some of the social and emotional deficit are present before onset, and that starvation makes them worse.  Patients in the acute phase of the illness will present with features similar to ASD. Probably about 20% will presnet with these features prior to onset of anorexia.   It is also possible that these deficits are more prevalant in the patients who go on to develop more serious froms of the illness and require an inpateint admission.

The similarity between the cognitive profiles of AN and ASD patients is striking.  The field of Autism is one in which the field of eating disorders should monitor for advances in understanding and treatment.

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Families and Eating Disorders

5/6/2011

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Thanks to Melinda Hutchings I read a blog by the director of the Eating Disorder Resource Centre, Dr. Judith Brisman.  Her blog discusses the possible role of family functioning in the development of eating disorders.  You can read her blog here.

She begins to allude to the concept of an "anorexicogenic family" where features of the family, particularly "enmeshment" and "overcontrol" were thought to be related to the development of an eating disorder.   As Dr. Brisman points out, the studies that described this were methodologically flawed and therefore inconclusive at best, and damaging to families at worst.  The concept seems similar to the "schizophrenogenic" family pattern that used to be thought to "cause" schizophrenia.  That is of course until we discovered that schizophrenia is a biological illness.  Dr. Brisman points to some studies indicating a biological basis to anorexia, but I will talk about those in a later post.

Dr. Brisman is correct when she asserts that ALL families, not just those with children with eating disorders, present with a combination of psychopathology, and strength and resiliency.  However, lets take those 1000 families that she wants to see in a research trial and then lets give their child a potentially chronic and life threatening disease.  We could choose an illness like leukaemia.  These families, I would boldly predict would demonstrate features like closeness and pulling together ("enmeshment") and maybe also try to control their distress in front of their child ("emotional overcontrol") and be worried about their child's activities and behaviour ("behavioural overcontrol").  I dare say these parents would demonstrate emotions and behaviour in line with an adjustment disorder, worry  and anxiety ("psychopathology").  

If we also treated these families as if they somehow caused the leukaemia (even if we didn't quite know how) and isolated them from the process of treatment, I suspect the parents behaviour may appear to be even more "pathological".  

My point is that we as clinicians (and as society) have a negative bias when it comes to mental health and we look for pathology where we would not in a medical condition.

Now, eating disorders are not quite like leukaemia are they.  Patients with leukaemia do not want their illness as someone with anorexia may appear to.  They will not fight against parents to help them.  They will not act to undermine treatment.  Thus, the parents of a child with an eating disorder are also faced with the egosyntonicity of the illness.  This feature of the eating disorders increases the difficulties parents face.  The frustration of wanting to help someone who actively resists help can be overwhelming for clinicians, let alone parents.  I suspect this part of the battle increases what we may see as "pathology" in the family.

So, Dr. Brisman's study not only needs to take 1000 families, but also needs to take into account the effects of having a child with a life threatening illness, the stigma of mental health, difficult access to treatment, and a child who resists treatment.  Given these conditions I would love to study the family that does not react in a way that could be considered as 'pathological'.   I strongly suspect that the family features that are seen to cause eating disorders are caused by a natural reaction to the trauma of  having a child with an eating disorder.  The research backs this hypothesis up.

Families are an important resource for treatment, particularly in children and adolescents.  The outcome of  patients treated with Maudsley Family Based Therapy is a testament to this.  We are currently looking at ways to increase support for parents whose children are suffering from the eating disorders to decrease there feelings of guilt and blame, and to increase their effectiveness into helping their children overcome these insidious diseases.


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    Author

    Chris Thornton is a Clinical Psychologist and the Clinical Director of The Redleaf Practice, a specialist outpatient clinic for the treatment of eating disorders.  He is interested in bringing elements of positive psychology, Cognitive Behavioural Therapy and Acceptance and Mindfulness approaches to the treatment of eating disorders.   

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