Autism and diet, by Janet Treasure


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Autism and diet, by Janet Treasure

  1. 1. Prof. Janet Treasure [email_address] . The relationship of eating disorders to ASD
  2. 2. Overview <ul><li>What are eating disorders </li></ul><ul><li>Links with ASD? </li></ul><ul><li>Cognition Set shifting </li></ul><ul><li>Cognition Central Coherence </li></ul><ul><li>Social cognition </li></ul>
  3. 3. EDNOS AN BN OCD spectrum Autistic spectrum Bipolar spectrum Addiction spectrum ADHD Affective Disorder The comorbidity of Eating Disorders
  4. 4. AN as empathy disorder <ul><li>AN autistic spectrum disorder </li></ul><ul><li>Narrow interest, repetitive behaviour </li></ul><ul><li>Not understand family distress </li></ul><ul><li>(Gillberg et al 1994, Wentz et al 2009) </li></ul>
  5. 5. Comorbidity AN & ASD <ul><li>Anorexia nervosa and autism co-segregate within families (Gillberg 1983, ) </li></ul><ul><li>20% autistic spectrum disorder (ASD) of cohort of AN ascertained from community at age 15. Continuing social impairments & poor outcome ( Gillberg et al 1994, Wentz et al 2009) . </li></ul><ul><li>26/ 30 (53%) adult female inpatients - childhood onset neuropsychiatric diagnosis. (23% ASD, 17% ( ADHD), 27% tic disorder (Wentz et al 2005 ). </li></ul>
  6. 6. At Risk Population (Coombs et al 2010) <ul><li>Age: 13 . School children m=61 f=71 </li></ul><ul><li>ASD traits correlate EAT traits </li></ul><ul><li>Attention to detail and communication difficulties predict EAT score with social skills protecting. </li></ul>
  7. 7. Broader Autism Phenotype ↑ Autism Traits ↑ Systematising Traits ↓ Empathising ↑ Male Brain ( Hambrook et al 2008, Baron-Cohen et al 2011, Lopez et al 2011)
  8. 8. A gender comparison high function ASD (Lai et al 2011) Male Female ADIR = = RME 22 22 AQ + ++ EQ/SQ = = Sensory + ++ ADOS Social communication +++ -
  9. 9. Cognitive overlaps AN &ASD <ul><li>ASD behaviours related to three cognitive domains/theories: </li></ul><ul><li>Executive dysfunction-set shifting. </li></ul><ul><li>Weak central coherence. </li></ul><ul><li>Poor theory of mind (low social cognition) </li></ul>
  10. 10. 1 6 7 8 9 10 5 2 3 4
  11. 11. 1 6 7 8 9 10 5 2 3 4
  12. 12. 1 6 7 8 9 10 5 2 3 4
  13. 13. 1 6 7 8 9 10 5 2 3 4
  14. 14. <ul><li>. Difficulty in changing cognitive set. </li></ul><ul><li>Once a rule is learned it is difficult to shift. </li></ul><ul><li>Mastery at adhering to laws of thermodynamics. </li></ul><ul><li>Linked to childhood OCPD features </li></ul>Tchanturia et al 2005, 2006 Roberts et al 2007 Rigidity
  15. 15. 2. I want to keep and maintain a specific weight and in order to do that I know there are rules…I have to control my intake 3. It’ s as if you have a calculator in your head totting up the intake and output. You are scientific about these laws of thermodynamics what things go in your rule system. <ul><li>4. Well there is the amount of exercise I do but that gets addictive more and more. </li></ul><ul><li>Walking at right angles rather than curves </li></ul><ul><li>The amount I sleep, I try to keep it short as you use fewer calories. </li></ul><ul><li>I would restrict the amount of tooth paste because fear of extra calories. </li></ul><ul><li>Avoid smelling food, if you can smell it there must be something there in your body you could absorb </li></ul><ul><li>If I cut my hair I would weigh that for my calculations </li></ul><ul><li>If my watch broke I would have to put something heavy on my wrist to compensate </li></ul><ul><li>If I lost a nose stud- I would have to have a replacement </li></ul>1. What is the worry about food? The therapist explores how detail of the AN rules impacts on eating
  16. 16. Embedded Figure Test
  17. 17. Fragmented Figure Task Acute AN> BN > Recovered> HC : Correlation with BMI
  18. 18. <ul><li>Inability to see bigger picture i.e. Not seeing the wood for the trees. </li></ul><ul><li>Heightened perceptual awareness. </li></ul><ul><li>Analytical, detailed focus. </li></ul><ul><li>Difficulty extracting gist. </li></ul>Lopez et al 2008a, 2008b, 2008c, 2008d Detail vs. Global Imbalance
  19. 19. Does your attention to detail have a negative side? For example are you hyper-sensitive to slight errors or mistakes eg music off key, flavours discordant, details off in some way? So everyone has their own cereal, everyone likes different cereals, so we have so many, and um we all like different cereals, and at the moment I like wheetabix and because everyone has two wheetabix’s and they are even because there are 24 wheetabix in the thing, because it is supposed to be even, because everyone is supposed to have two and that’s what’s normal, which I am trying to be normal. And, things that annoy me, it got down to the end one day and there was one left, I took two and I was like ‘why is there one left?’ because I had two, because I am the only one that eats this. And then I said to mum, obviously someone else has had some wheetabix and I was like but that means they have only had one and that’s not normal and so she was like maybe they had one wheetabix and some of their cereal… She was trying to make me relax…. dad he sort of brought it up a few days later, he goes, well I am worried that you start counting things………
  20. 20. Food and Exercise Rituals (Age 11 yrs) <ul><li>I exercised to relieve anxiety. I set myself daily exercise goals that I had to achieve to prove to myself that I was not a worthless person. </li></ul><ul><li>Same exercise routine, same times of day, sometimes more, but never less. If I didn’t achieve my exercise goals I sometimes cut myself or sat in a cold bath as ‘punishment’. </li></ul><ul><li>Cut out all ‘bad’ foods and made lists/plans of what I ‘could’ eat and what I ‘couldn’t’ eat. </li></ul><ul><li>Made lists of calories, grams of fat, protein and carbohydrate in all food consumed. Reading nutrition charts became an enjoyable hobby. </li></ul><ul><li>My food and exercise routines felt like my ‘life-plan’. If I followed this plan precisely, everything would be OK. </li></ul>
  21. 21. Cognitive overlaps AN &ASD <ul><li>ASD behaviours related to three cognitive domains/theories: </li></ul><ul><li>Executive dysfunction-set shifting. </li></ul><ul><li>Weak central coherence. </li></ul><ul><li>Poor theory of mind (low social cognition) </li></ul>
  22. 22. Baseline Low Social worth Loneliness, shyness, and inferiority in childhood and adolescence (Fairburn et al 1999) Social anxiety (Penas lledo et al 2010) Submissive and striving behaviours ( Connan et al.,2003 2007, Troop et al., 2008, Troop et al., 2003).
  23. 23. <ul><li>Punish vs. reward </li></ul>Attention bias to negative Attention bias Away from positive
  24. 24. <ul><li>Attention to Accepting/Rejecting faces </li></ul>Immediate Delay
  25. 25. Reduced Emotional Regulation - - <ul><li>ED longer to name the colour for faces. </li></ul><ul><li>More distracted by non verbal emotional signalling of threat and ambiguous faces </li></ul><ul><li>Large effect in acute state. Medium effect in recovered </li></ul>Harrison et al 2009, 2010
  26. 26. Emotional Expression Congruence expression/experience AN HC Attention HC AN H Davies K Tchanturia U Schmidt
  27. 27. Impaired Reading Mind Others Oldershaw et al. (2010.) OK Moderate effects which other than eyes task improve after recovery
  28. 28. Understanding how others think not just what they say “ Just back up little dear, so you won’t cut my head off” About 20% of people with anorexia nervosa have some difficulty with this. Tchanturia et al 2004, 2009.
  29. 29. Interpersonal Difficulties <ul><li>Age 8-9 yrs: traumatic events which confused me and made me feel that I was a ‘bad’ person. </li></ul><ul><li>Age 9-11 yrs: bullied by a ‘pack’ of girls. This increased my fear of other people and my sense of being ‘abnormal’ and worthless. </li></ul><ul><li>Flirtatious comment by older male schoolteacher led me to be terrified of ALL men. </li></ul><ul><li>I felt different – as if I was ‘all wrong’. I felt I didn’t ‘fit in’ anywhere. I didn’t know who I was, and I was terrified of the future. </li></ul>
  30. 30. Conclusion <ul><li>Some of the social cognition deficits may be secondary to the illness . </li></ul><ul><li>Others such as extreme shyness, social phobia may be innate </li></ul>
  31. 31. The patients voice: <ul><li>Despite being weight recovered, the obsessional eating, tendency for rituals and desire for control/predictability, rigidity and order are all things I still struggle with. </li></ul><ul><li>If I fail to eat a meal in a certain way I still panic - it feels 'wrong'. The panic is not linked to my weight or body image.  </li></ul><ul><li>  I had rituals as a young child, long before the trauma that triggered my anorexia nervosa. My father is the same. </li></ul><ul><li>The way that I reacted to the trauma of sexual abuse was to engage in exercise and food rituals, which seemed to contain my anxiety. </li></ul><ul><li>I felt particularly bound by the exercise rituals, which I always performed at the same time of day, on the same treadmill in the gym and to the point of physical exhaustion.  </li></ul><ul><li>Any change of routine and I panicked. The panic also had 'meaning' as well as feeling 'wrong' - e.g. 'I haven't managed to complete the usual number of minutes at a particular intensity and so I am a failure and not worthy of existing'. </li></ul>
  32. 32. <ul><li>Currently ill AN patients have impaired set shifting and detail/global balance similar degree to those observed in ASD. </li></ul><ul><li>Currently ill AN patients have impaired emotion recognition and eToM ability similar degree to those observed in ASD. </li></ul><ul><li>.Recovery is associated with improvement in some aspects of social emotional functioning and more flexibility. </li></ul>Summary of Findings
  33. 33. EDNOS AN BN OCD spectrum Autistic spectrum Bipolar spectrum Addiction spectrum ADHD Affective Disorder The comorbidity of Eating Disorders
  34. 34. Conclusions <ul><li>All acute AN can have Pseudo ASD features </li></ul><ul><li>Also 20% may be high functioning female Aspergers </li></ul>
  35. 35. The patients voice: post recovery <ul><li>I am 55 now and recovered from AN in my early 30s after 10 years of illness.  </li></ul><ul><li>However I have continued to struggle with episodes of depression and am now on long-term antidepressants.  </li></ul><ul><li>I continue to find life very difficult and keep getting into difficulties with jobs - expecting people to be perfect, and rules to be logical. </li></ul><ul><li>There seems to be no end to it although I try desperately to be tolerant and shrug my shoulders.  </li></ul><ul><li>I am also very socially isolated </li></ul><ul><li>I am divorced with two lively teenage boys. </li></ul>
  36. 36. Final Conclusion <ul><li>AN & ASD share weak coherence and this may be a risk factor possibly associated with OCPD traits. </li></ul><ul><li>Starvation increases rigidity & OCPD traits. </li></ul><ul><li>Starvation decreases social cognition. </li></ul><ul><li>Starvation decreases emotional regulation. </li></ul><ul><li>Starvation shifts reward from people onto food alone. </li></ul><ul><li>People with acute AN resemble ASD </li></ul><ul><li>People with ASD at risk of eating disorders </li></ul>
  37. 37. Acknowledgements Nina Jackson (RIED), NIHR, BRC
  38. 38. ‘ Triad’ of three basic problems in ASD (Wing and Gould) <ul><li>i. Impairment of social interaction </li></ul><ul><li>This refers to the marked reduction of non-verbal signs of interest in and pleasure from being with another person . </li></ul><ul><li>ii. Impairment of social communication </li></ul><ul><li>This refers to the decreased ability to ‘‘converse’’ non-verbally and verbally with another person, sharing ideas and interests or to negotiate in a positive friendly way. </li></ul><ul><li>iii. Impairment of social imagination </li></ul><ul><li>This is the decreased capacity to think about and predict the consequences of one’s own actions for oneself and for other people. </li></ul>
  39. 39. AQ: Short traits <ul><li>Detect small sound </li></ul><ul><li>See details vs big picture </li></ul><ul><li>Difficult to multi-task </li></ul><ul><li>Not easy to get back task when interrupted </li></ul><ul><li>Not find easy to read between lines </li></ul><ul><li>Not find easy to know someone listening to me bored. </li></ul><ul><li>When read story difficult to know intentions </li></ul><ul><li>Like collect information about categories eg birds, plants </li></ul><ul><li>Not easy to know what people think via faces. </li></ul><ul><li>Difficult to know peoples intentions. </li></ul>
  40. 40. Girls With Social and/or Attention Deficits: N= 100, Age 7-16 Clinic Attenders (Kopp et al 2010) <ul><li>Comorbidity of girls ASD </li></ul><ul><li>35% OCD </li></ul><ul><li>30% Social phobia </li></ul><ul><li>40% Specific Phobia </li></ul><ul><li>35% > 2 anxiety disorders </li></ul><ul><li>5% Eating Disorder </li></ul><ul><li>40% Sleep Disorder </li></ul><ul><li>35% depression </li></ul>