Eating Disorders

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While growing up, Seren Sonell, a 32-year-old theater artist in New York City, had an aversion to hard, crunchy, and cold foods, as well as fruits and vegetables. Food aversions are common among people with autism spectrum disorder (ASD), especially children, and Sonell, who has autism, has eaten a limited diet for as long as she can remember.

During her senior year of college, Sonell's coursework became overwhelming and required increasing amounts of her attention. This led her to avoid components of her life that were hard or required extra effort. In light of her food restrictions, meal preparation fell into that "not so easy to do" category, and she ended up eating just one meal per day. “The resultant weight loss was really exciting to me,” Sonell says. "It became addicting." Along with food aversions, autism traits such as cognitive rigidity (needing to do things a certain way) can lead to this kind of restriction around one’s diet.

Research suggests an overlap exists between autism and eating disorders: Around 20 to 35 percent of women with anorexia, compared to just one percent of the general population of women, meet the criteria for autism.

Similar correlations exist between autism and other eating disorders, like bulimia and binge eating disorder. People with autism are also more likely to end up diagnosed with avoidant/restrictive food intake disorder (ARFID), which involves highly restricted or selective eating that is not motivated by body image issues.

Eating disorders are common among people with autism, and may present differently than they do for people who are neurotypical.

In addition to food aversions and difficulties with body awareness, a number of other traits associated with autism may contribute to eating disorders. Some people with autism, for instance, are prone to body-image distortions due to differences in how they process visual information. While people who are neurotypical are more likely to look at themselves and see all of their features together, people with autism may be prone to fixating on a singular body part.

People with autism are also susceptible to feelings of overwhelm and overstimulation due to their sensory sensitivity and difficulty in processing emotions. "This can lead to feelings that are difficult to manage, and disordered eating can become a way to get a hold on these emotions," says Corrie Goldberg, PhD, a licensed clinical psychologist who works with people who are neurodiverse.

"Those with autism are more likely to have experienced subtle and direct feedback throughout their lifetime that they should behave in ways that feel unnatural to them, known as masking, in order to better fit in with peers or with broader society,” says Dr. Goldberg. “This pressure to deny their own instincts and prioritize the comfort of others can contribute to a decreased ability to notice and respond to their own needs in a healthy way, which can extend to their relationship with food and their bodies.”

This is one of the many reasons why people with autism benefit from seeing providers who are open to them expressing themselves however feels natural to them, rather than expecting them to act like people who are neurotypical. “I have a client who tends to ‘giggle’ when stating thoughts from the eating disorder,” says Michelle Hunt, LMHC, NCC, a licensed therapist with Empower Your Mind Therapy. “While this could be assumed to mean that she is not taking the eating disorder seriously, as stated by other providers, what it actually means is that the eating disorder thoughts create sensory overload, which in turn needs to be expelled. In this case, the expulsion of the energy is giggling.”

Finally, another common feature of autism is “over-reliance on routines and more rigid thinking, which usually comes with 'rules,'” explains licensed clinical psychologist Jephtha Tausig, PhD. This, she says, can translate to rigid behaviors around food.

For a person with autism at any age, developing a healthy relationship with food may involve finding healthy meals to eat that don’t trigger dietary aversions or cause digestive issues, which are also common in people with autism," says Cash. You might slowly introduce foods into your diet that are similar to ones you already like, and then, eventually, you'll end up with a diversified diet and fewer aversions. For instance, Cash worked with one four-year-old who almost exclusively ate chicken nuggets and would have meltdowns when their parents tried to serve vegetables. This child had more success learning to eat mozzarella sticks and fish sticks before tackling broccoli and brussels sprouts.

Some signs of eating disorders resemble signs of autism, making it easy to unintentionally overlook certain symptoms in people with autism. “Weight fluctuations, menstrual irregularities, dizziness, syncope [fainting], feeling cold all the time, weakness, and fatigue should not be ignored in any person who also has autism spectrum disorder," says Anna Tanner, MD, FAAP, FSAHM, CEDS-S, vice president for the Department of Child and Adolescent Medicine at Veritas Collaborative eating disorder treatment center and The Emily Program. "They should instead be evaluated by an experienced professional with a background in eating disorders.”

For instance, people with autism may need to pace or move around to discharge feelings of overwhelm after eating, says Hunt. “Splitting therapy sessions in half—half of the time dedicated to food, the other half processing—can be beneficial, as is adding more sessions throughout the week at varying times,” Hunt says. “Find providers who can empathize with the sensory processing needs.”

About two years after her one-meal-a-day routine began, Sonell realized her eating was disordered and began trying to eat in a more balanced manner. She left school to reduce her stress, and her eating improved as well.

Sonell also learned to lean in to one of her autism traits: her desire for order. “I have a brain that craves and thrives in strict structure, so I've actually started planning roughly the same times for breakfast, lunch, and dinner,” she says. “I'm also really careful to always keep some of my 'safe' foods around—things that, taste and texture-wise, are basically universally pleasant for me.” This way, Sonell says that she always has something that she finds palatable and comfortable to eat.

Recovery for anyone, whether they have autism or not, is not just about normalizing eating: It’s an emotional and spiritual journey. Recovery is also an ongoing process, which means it may require a caregiver to forgive moments of relapse as well as celebrate small victories along the way.

Autism and Anorexia
The overlap between repetitive and rigid behaviors is one example of the commonalities between anorexia nervosa and autism. Anorexia is an eating disorder characterized by rigid attitudes and behaviors surrounding food, weight, and body image. These narrow interests and repetitive behaviors mirror the preoccupation with certain objects and/or topics in autism.

Research shows that the prevalence of autism in anorexia populations is between 8% and 37%, with an average of 22.9%. These rates are dramatically higher than the reported autistic prevalence in the general population, which is about 1%.

Autism and ARFID
The overlap in hyperreactivity to sensory input is one example of the commonalities between ARFID and autism. In fact, the overlap is so significant that research shows up to 30% of individuals who struggle with ARFID also have an autism spectrum disorder diagnosis.

A common attribute of ARFID is a hyperreactivity to the sensory components of foods leading individuals to avoid new foods or only eat a small variety of options. One diagnostic feature of autism is repetitive or restrictive patterns. Within this diagnostic category are several examples, including the need to eat the same food every day and/or a hypersensitivity to sensory input. Both diagnostic features can be traits of individuals diagnosed with ARFID.

Unique Considerations for Female-Identifying Individuals
Masking
Selective mutism or extreme quietness
Special interests in “socially accepted” topics
Misdiagnosis: Nearly 50% of all females with autism are misdiagnosed at least once in their lifetimes. Common misdiagnoses given to females with autism are borderline personality disorder or bipolar disorder.
Food aversions and sensitivities that progress into eating disorder behaviors: Due to societal pressures surrounding beauty standards and how to behave, females with autism are more likely to develop eating disorders, such as anorexia or ARFID.

Female Autistic Characteristics and Risk of an Eating Disorder
Misdiagnosis leading to internalized shame: Females with autism are far more likely to go misdiagnosed, which leads to treatment interventions unrelated or damaging to their actual challenges. Misdiagnosis and improper treatment lead many individuals to hold on to shame regarding who they are rather than an understanding of how to celebrate their unique interaction with the world.

Social ostracization: Social ostracization and bullying aren’t only experienced by females with autism. However, due to improper or a lack of diagnosis, social ostracization among females can lead teachers, parents, and professionals to respond in ways that are unsupportive. For example, an undiagnosed autistic female is mute in the classroom due to social confusion and extreme social anxiety. A parent may respond by saying, “You need to talk to more people.” Though the parent is trying to offer advice and support, this statement may lead to further social confusion and internalized shame for not being able to “just talk more.”

Societal pressures: Females have the unique challenge of managing intense societal pressures. Society has strong expectations for how females should act and appear. These expectations, in addition to the social confusion and rigidity experienced by autistic females, may lead to rigid patterns and repetitive behaviors with food.