Alexithymia , autism and eating disorders are sophisticated conditions that have garnered significant attention in recent years these conditions have dramatic effects on mental and emotional well-being one of the specific psychological variables that contribute to the etiology of eating disoders and autism is emotion regulation ability Alexithymia is sub-clinical phenomenon not identifying a personality disorder per se, but a personality trait with a dimensional nature construct of alexithymia , difficulty in identifying feelings, difficulty differentiation between typical bodily processes ( Hunger cues exhaustions externally oriented thinking where the clients are paying more attention to external things arond than to internal experiences difficulty of describing emotions Autism eating experience and sensory processing constructs , exteroception, interoceptive

1. @iaedp
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2. @iaedp
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 Alexithymia, autism spectrum disorders, and
eating disorders are sophisticated conditions that
have garnered significant attention in recent years.
 These conditions have dramatic effects on mental
and emotional well-being.
 A profound understanding by an in-depth analysis
of these interconnected topics, highlighting their
characteristics, challenges, and potential
interventions will carry a better intervention and
satisfactory responses .

3. @iaedp
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 The prevelance of Autism and Eating Disorders has been
reported to increase in recent decades .
 One of specific psychological variables that may contribute to the
etiology of Eds and autism is emotion regulation ability
 One situation that impede the regulation of emotion is
Alexithymia
 Alexithymia as an important risk factor for psychopathology
symptoms due to its impairing effect on emotion regulation ability.
 So examining the mediating role of Alexithymia on uncovering
the relationship between autism and Eds is of great importance
Available from:
https://www.researchgate.net/publication/374086977_Alexithymia_a
nd_eating_disorder_symptoms_the_mediating_role_of_emotion_reg
ulation [accessed Oct 06 2023].

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 What is Alexithymia ? Definition, neuroanatomy,
core characteristrics and psychological construct .
 Know how the DSM-5 disgnosing either feeding
and eating disoders and Autism
 Define the overlap between autism and ED.
 Explore the mediating effect of alexithymia on the
relationship between autism and ED.
 Does the Intersection Between Eating Disorders
and ASD exist?
 Understand the Management plans for
individuals with Autism and Eds

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This Photo by Unknown Author is licensed under CC BY
Alexithymia is not a new concept. Sifneos
(1973) explain a group of cognitive and
affective characteristics typical of many clients
with somatic disorders.
Currently, it is identified in eating disorders,
Autism, substance abuse, depression,
personality disorders
It is a stable personality trait reflecting an
impairment of emotion regulation not linked to
any clinical status
Alexithymia is considered a “sub-clinical
phenomenon” not identifying a personality
disorder per se, but a personality trait with a
dimensional nature

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 Alexithymia is the product of developmental dysfunction
of, or reduced connectivity between, limbic structures,
including the anterior insula (AI) and anterior cingulate
cortex (ACC).
 AI, ACC are the regions implicated in the subjective
experience of emotion, affect recognition and empathy.
 Studies suggested that both of these regions failed to
show the typical modulation of cerebral blood flow when
alexithymic participants viewed angry faces

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 Today alexithymia This is characterized by an impairment in the
awareness of emotions due to a deficit in processing of affective
information (Vermeulen et al., 2006).
 The Main Characteristics of Alexithymia Include
1. Difficulty identifying feelings and describing feelings
2. Difficulty differentiating between typical bodily processes(
Hunger cues, exhaustions(anxiety , sadness)
3. Reduced capacity to fantasize and to generating mental
imagine.
4. Stimulus-bound, externally oriented Thinking (paying more
attention to external things happening around than to internal
experiences (Taylor et al., 1997; Timoney and Holder, 2013),
5. Low perspective-taking as well as difficulty understanding and
describing the emotions of others (Saymur et al., 2013)

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Cognitive factors
of Alexithymia
Affective factors of
Alexithymia
Deficits in the regulation of thoughts,
emotions and bodily processes
•Difficulty with interoception
Inhibition and impulsivity issues Blunted or limited personal experience of
emotions
Limited imagination and fantasy life Difficulty identifying and describing
emotions
Constricted patterns of thought Emotion dysregulation
Reliance on concrete thinking almost to
the exclusion of symbolic thinking
Failure to identify the causes of
personal feelings
Lack of empathy
Limited use and understanding of verbal
and nonverbal emotional cues

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Physiological Factors
with Alexithymia
Social Factors With
Alexithymia
Physical sensitivity to the
experience of different sensations
•Nonassertiveness
Tendency to mistake affective
responses as physiological
experiences or dysfunctions
Verbal and nonverbal
communication deficits
Loneliness
Weak social attachments

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In the general population have been reported as follows:
 Anorexia nervosa (AN): 0.8-2.6%
 Binge eating disorder (BED): 0.6-6.1%
 Bulimia nervosa (BN): 0.8-2.6% (Silén & Keski-Rahkonen, 2022)
 Avoidant restrictive food intake disorder (ARFID): 0.3%
(Hay et al., 2017)
 Pica: occur in up to 5% of 7 to 13-year-old children (Murray
et al., 2018)
 Rumination: has been reported to occur in less than 3%
of 7 to 13-year-old children (Murray et al., 2018).
 Other specified feeding and eating disorders (OSFED): 0.6-
11.5%
 Unspecified feeding and eating disorders (UFED): 0.2-
4.7%

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Feeding and eating disorders are characterised by:
 Disturbed eating and eating‐related behaviours that
significantly impair one's physical and mental health
(American Psychiatric Association, 2013).
 EDs have the highest mortality rates of all mental health
disorders and exhibit a concerning resistance to
treatment
 Highlighting a pressing need for a greater understanding
of their aetiological mechanisms
(Treasure, 2019; van Eeden et al., 2021),

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 The current meaning of the term ‘autism’ was
developed and attributed to Asperger
(1938, 1944), while the lemma ‘infantile autism’
was introduced by Kanner (1943).
 Asperger and Kanner used the term to indicate a
disorder of organic origin with severe behavioral,
affective, communication and social skills
impairment, characterized by little interest in
others, speech disorder, attention deficit and
compulsive and repetitive behavior.

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 The publication of the DSM-IV (1994) placed autism in the wider
category of pervasive developmental disorders, a complex of
syndromes that affect
 Social interaction,
 Communication and the capacity to develop varied interests.
 Later of the DSM-5 , a view of autism was gradually developed
based on the idea of a spectrum:
The adoption of the term ASD
Autism is no longer seen as a categorical condition
Including anomalies in sensorial perception often display
inexact sensorial processing, ranging from a lack of response
to exaggerated reactions to sensorial stimuli
Thus, the clinical picture of ASD may vary in its symptomology
and severity
(American Psychiatric Association [APA], 2013),

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 Hyper-or hyporeactivity to sensory input or unusual interest in
sensory aspects of the environment (e.g., apparent indifference to
pain/temperature, adverse response to specific sounds or textures,
excessive smelling or touching of objects, visual fascination with
lights or movement).
 Although global emotional deficits, lack of empathy and impaired
recognition of emotion in others , are not currently a diagnostic
feature of autism.
 A Close examination of the literature reveals wide heterogeneity
within the autistic population with respect to emotional competence.
 Here we argue that, emotional impairments are due to alexithymia—
a condition that frequently co-occurs with autism—rather than a
feature of autism per se.

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 A substantial body of literature evidencing links
between neurodivergence and eating disorders
 Research demonstrates that feeding difficulties and
eating disorders are overrepresented in
neurodivergent people, including:
◦ Autism
◦ ADHD
◦ Intellectual disability
◦ Giftedness
◦ Tourette’s disorder.
 Awareness among clinicians and researchers of this
existing knowledge base is very interesting.

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 Many researchers have sought to understand the relationship and
prevalence of autism or autism under-diagnosed in people with
eating disorders (and vice versa).
 Mayes and Zickgraf (2019) found that around 70% of autistic
children demonstrated ‘atypical’ eating behaviours
 Autism Feeding difficulties are commonly reported to occur in
autistic children (Conklin, & Watson, 2022;).
 Leader et al. (2021) found that 90% of parents or caregivers
reported their autistic child experienced feeding difficulties.
 The variation in prevalence estimates is likely driven by a lack of
consensus regarding definitions of what constitutes ‘atypical’
eating behaviours and feeding difficulties, alongside the use of
different measurement tools and sample populations

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Many characteristics seen in Autism and
people with eating disorders as :
Selective eating requirements
Sensitivity to the textures, look, smell or sound
of foods, which can lead to food aversions.
Social aspects of eating (such as sitting at a
table with others, waiting until others are
finished) .
Swallowing difficulties such as oral problems
(difficulties chewing or) or gastrointestinal
problems, which make eating a non-pleasurable
experience.

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1- Exteroception :Autistic have atypical reactions
to what they see, hear, smell, touch or taste.They
heightened sensory issues as the textures, look, smell
and sound of foods
2- Interoception
Is the process of perceiving senses inside the body,
such as hunger, thirst, fullness and pain
. Autistic experience interoception confusion, which
can make intuitive eating challenging.
3- Alexithymia
Autistic with alexithymia have a hard time pinpointing
what emotion they are feeling and also not be able to
communicate what they are feeling to others. This can
make it hard to soothe themselves or get support from
others and can make them more vulnerable to
developing eating disorder symptoms as a coping
mechanism (Vuillier et.al, 2020).

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Sensory Processing defecit :
This can make it hard to soothe themselves or get support from
others and can make them more vulnerable to developing eating
disorder symptoms as a coping mechanism
All interact with and influence body image, eating and feeding
behaviours, and other activities of daily living in different ways.
The main constructs pertaining autism eating experience are
I. Exteroception,
II. Interoception,
III. Alexithymia

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 Exteroception refers to the perception of stimuli from the
external environment. It does this via the sensory receptors
located on the body’s surface. Such as the skin, eyes,
ears, nose, and mouth.
 It allows individuals to gather information about their
surroundings, including temperature, pressure, sound,
light, and smell.
 Exteroception is essential for many daily activities, like
navigating through a crowded street, communicating with
others, and enjoying the taste and smell of food.
Jean- paul Noel et. al., 2018

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 Exteroception can be explained by brain connectivity
differences, two mechanisms either by weak neural
synchronization or by atypical perceptual inference.
 Both the weak neural synchronization and atypical
perceptual inference might be complementary neural
mechanisms that describe the complex bottom-up and
top-down differences of autistic perception, respectively.
 Divergent patterns of sensory processing either
exteroceptive and interoceptive sensory processing may
contribute to prototypical social and cognitive
characteristics of autism may drive new directions in our
conceptualization of autism eating Experience
American psychological association 2021
Proff, I., Williams, G. L. 2023

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Sensory processing :
The main constructs pertaining to sensory processing are
I. Exteroception,
II. Interoception,
III. Alexithymia
All interact with and influence body image, eating and
feeding behaviours, and other activities of daily living in
different ways.

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- Interoception, referred to as the ‘eighth sense’ beside
the known senses (sight, smell, taste, touch, hearing,
proprioceptive, and vestibular senses).
-- Interoception refers to the perception and
awareness of physiological sensations, such as heart
rate, respiratory effort, temperature, fatigue, hunger,
thirst, satiety, muscle ache, pain and itch

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 The interoceptive sense has
receptors in various parts of the
body, in the organs, skin, and
muscles
 These receptors capture
sensorial information and send
it to the brain, specifically the
insula, where they are
translated into a clear message
of what the body is feeling and
experiencing

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The ability to interocept has three-
dimensional model :
1- Interoceptive sensitivity refers to the
objective accuracy of one's interoception (e.g.
ability to perceive accurately one's heart rate).
2- Interoceptive sensibility, assesses
one's subjectively perceived sensitivity (the
extent to which one believes at perceiving
bodily states)
3- Interoceptive awareness is
responsible for keeping our body in
homeostasis, telling us to get a snack when
we're hungry or go to the bathroom when our
bladder is full. It balances the need for change
with the need to stay the same

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 Difficulty sensing body signals can lead to various mental
health disorders, such as eating disorders
 The socio-emotional deficiencies among ASD patients
may be related to difficulties in perceiving internal bodily
signals due to inadequate emotional awareness.
Lack of interoceptive awareness can
contribute to the onset and continuation of the
Eds specially Anorexia nervosa , ARFID and
Autism
(Nandini Datta & James D. Lock 2023)
,,

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 ARFID had difficulty with interoceptive accuracy
and listening to their bodies, but they had good
awareness overall of their accuracy.
 AN had better accuracy but were more unsure
about trusting their body and body signaling.
 Overall, findings suggest that how individuals with
eating disorders sense, interpret, and respond to
body signals might help explain their eating habits.

28. @iaedp
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Sensory processing :
The main constructs pertaining to
sensory processing are
I. Exteroception
II. Interoception,
III. Alexithymia

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 Alexithymia was found to be more prevalent in females than in males,
associated with higher levels of sub-clinical disordered eating in
undergraduate females .
 Alexithymia underlie particularly difficulties identifying and
describing their feelings.
 Alexithymia implicated in the development , maintenance and
poorer outcome from EDs , making it a relevant treatment target.
 Alexithymia interfere with both treatment compliance and patients’
ability to benefit from the known interventions.
 For this reason, in the last years new treatment approaches targeting
emotion identification, expression, and regulation have been
applied .
Heather Westwood et., al.,2017

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 Prevalence rates of alexithymia in individuals with AN
have been reported to be 77.1% (compared to 6.7% in
healthy controls) (Bourke et al., 1992)
 In a sample of 93 individuals with BN, Schmidt et al.
(1993) found that 50% met the clinical threshold for
alexithymia, while only 19% of the 95 healthy controls met
this criteria.
 In a sample of 83 individuals with BED, 24.1% met the
clinical threshold for alexithymia, exceeding the 11.1%
among the control group (de Zwaan et
al., 1995).
(Moseley et al., 2023; Vuillier et al., 2020).

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 There are a growing acceptance that the incidence of
severe alexithymia is substantially elevated in the autistic
population
 The rates of alexithymia in the ASD population range from
40% to 65% . Recently, Ben Hassen et al.2021, explained
that difficulties in emotion recognition and empathy,
commonly associated with ASD, may in fact be due to the
presence of alexithymia rather than ASD per se

32. @iaedp
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Samples A , autistic population
contain a high alexithymia
symptoms
Samples C contain relatively few
individuals with co-occurring
alexithymia
Sample B comprising a mix of
individuals with varying degrees of
co-occurring of Alexithymia
Conclusion :
 weak inconsistent trends toward
emotional deficits across Autism
 Heterogeneity of Autism
conclusion
A C
B

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 Autism have difficulty in social relationships
characterized by:
- Intimacy and proximity,
- Understanding the intentions and attitudes of others,
- Difficulty making morally relevant decisions that take
into account others’ points of view.
 These aspects of alexithymia together with the
communication and social skills deficits are among the
most relevant overlapping elements between alexithymia
and ASD

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 There is a disproportionate prevalence rate of autism in
ED population (Mandy, et al., 2017; Westwood et al., 2018)
 Poorer treatment outcomes and prognosis are associated
in individuals with both autism and ED
 High prevalence rates of alexithymia among both autistic
populations and ED populations suggest that alexithymia
may have a mediating effect between autism and EDs
 Decreased interoceptive awareness is a common trait of
autism and Eds and may pose challenges when identifying
hunger versus satiety
(Bentz, Jepsen, Pedersen, et al., 2017; Tchanturia et al., 2016, 2019).
(Conway et al., 2018; Kinnaird et al., 2019; )

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 Alexithymia would mediate the association of autism symptomatology in
individuals with ED.
 Hobson et al. 2020 , found that individuals with AN have an increased
likelihood of reaching the diagnostic threshold for autism if they
experienced comorbid alexithymia
 It is estimated that roughly half of autistic individuals endorse traits of
alexithymia (Cole et al., 2023; )
 This can make it difficult for Autism individuals to express or explain
emotional or psychological distress, including that underlying eating
disorders.
 Presence of Alexithymia should to be taken into consideration as it
influence the treatment outcomes (Gramaglia, Gambaro, & Zeppegno,
2020)

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 Individuals with AN may display traits of autism
including :
 High levels of negative affectivity,
 Blunted facial affect,
 Perfectionism,
 Deficits in theory of mind,
 Challenges interpreting emotional states of others
 Traits of poor executive functioning in AN typical
to autistic individuals such as:
challenges with planning and organization have also been
reported in women with AN
(Tchanturia et al., 2013 , Leppanen et.al., 2018).

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 Although some argue that autistic
traits may arise as a result of
malnourishment in individuals with
eating disorders
 In 2018 study found that improvement
in eating disorder symptoms after 12
months appeared to be similar in
individuals both with and without
characteristics of autism, but social
difficulties remained significant in
participants with characteristics of
autism, indicating that these autistic
traits are not simply due to the
cognitive impact of starvation (Nazar
et al., 2018)

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 In the early 1980s, Christopher Gillberg first identified a possible
link between anorexia nervosa and autism.
 In a sample of 132 female individual , 66 with AN and 66 healthy
controls, found that 25.8% of participants with AN met the clinical
cutoff for autism, while only 1.5% of healthy control participants
scored within the clinical range.(Tchanturia et al., 2013)
 A cross-sectional observational study of female individuals with
AN in both inpatient and day-patient treatment programs found
that 10% of subjects had potentially diagnosable autism
spectrum disorder (ASD), as determined by both developmental
history and the Autism Diagnostic Observation Schedule (ADOS-
2), while 40% showed ASD symptomatology (Westwood et
al., 2018).
 In another study, 30 female ED patients, 23% of them met clinical
criteria for autism (Wentz et al., 2005),

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 Studies have also found that there may be a genetic or
familial link between anorexia nervosa and autism and that
the conditions have neurobiological links (Koch et.al., 2015).
 It may be that body image is less of a concern for autistic
people with anorexia but diet restriction used as a coping
mechanism to mask emotions and anxiety (Brede et.al., 2020).
 Many autistic women also report using food restriction to
gain social acceptance by meeting our society’s emphasis
on thinness.
 There may also be a tendency for repetitive behaviours
taking the form of an intense interest (such as calorie
counting or exercise) which develops into anorexia
(Westwood & Tchanturia, 2017).

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 Avoidant/restrictive food intake disorder (ARFID) is defined by
the DSM-5 as an eating or feeding disorder characterised by a
persistent and disturbed pattern of feeding or eating that leads
to a failure to meet nutritional/energy needs.
 ARFID is similar to anorexia nervosa in that a person restricts
their food intake but not concerned to weight gain or body
shape.
 Autistic people who are underweight or struggle to meet
nutritional needs from food may meet the diagnostic criteria
for ARFID (Mayes & Zickgraf, 2019).

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 Individuals with alexithymia typically have worse
mental health treatment outcomes than those
without alexithymia.
 The symptoms of alexithymia undermine the
development of :
1. Therapeutic alliances with mental health professionals.
2. Poor treatment engagement.
3. Interpersonal closeness deficit with others, due difficulties with
recognizing and describing affective experiences
4. Poor treatment attendance and adherence, so failure to
complete treatment programs and relapses

42. @iaedp
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 For better enhancing quality of life and improving long-
term outcomes in the ED population :
1. Screening for Alexithymia
2. Leveling of Alexithymia
3. Identifying interventions that improve outcomes for individuals with
alexithymia
4. Exploring new treatment approaches targeting emotion
identification, expression and regulation
NB: In EDs patients, alexithymia levels remain elevated
even after treatment. Whether alexithymia should be
considered a state-dependent variable or a trait remains
open to debate.

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 Toronto Alexithymia Scale (TAS-20)
 The Emotion Regulation Questionnaire (ERQ) measures
the use of two emotional regulation strategies, cognitive
reappraisal, and expressive suppression
 The Self-Awareness Questionnaire

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 Self-reporting, 20-item instrument using a 5-point Likert-type scale (1 =
strongly disagree and 5 = strongly agree)
 Evaluates alexithymia in 3 cognitive-affective areas: (1) difficulty in identifying
feelings, (2) difficulty describing feelings, and (3) externally oriented thinking.
 Scores between 52 and 60 indicate possible alexithymia and a score of 61
indicates the presence of alexithymia .
 The higher the score, the greater the inability to recognize one’s own
emotions. It has a Arabic version . Internal consistency of the tool for this
study was considered excellent (α = 0.82)

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 A self-reporting scale that measures interoceptive confusion
among adults with ASD, using language that is natural and
understandable for this population .
 The tool consists of 20 items using a 7-point Likert-type scale (1 =
totally untrue for me and 7 = total true for me).
 A score of 70 indicates interoceptive confusion, that is, greater
difficulty in interception. Scores equal to or above 94 indicate a
high degree of interoceptive confusion.

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 Standard eating disorder treatments tend not to accommodate the specific needs of
autistic people.
 Autistic people experiencing eating disorders may need access to a treatment plan
that is not only aware of their autism, but actively understands it and allows treatment
to be responsive to the needs of the individual.
 Treatments that require a person to make dramatic changes to their eating routines in
a short period of time may be ineffective for people with autism who simply require
more time and a more gradual process of change.
 Autistic people may require less food choices and more clarification around rules and
expectations in recovery.
 Overall, the recovery prospects and outlook are not any different to non-autistic
people, but longer and more intensive treatment may be required. (Tchanturia et.al.,
2019, Stewart et.al., 2017)

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 Given that long-term treatment outcomes are significantly worse for
individuals with comorbid AN and autism
 In Eating -Autistic individuals , following ED recovery symptoms as
social difficulties, decreased empathy/emotional recognition, reduced
eye contact, detail processing, and cognitive rigidity appear to persist
following treatment
 Examining the role of alexithymia as a potential mediator of the
relationship between autism and ED is also critical.
 Persistence of Alexithymia is problematic as it will increased risk of
suicide, self-injury, and substance abuse, as well as decreased
response to psychological therapy and drug treatment
(Bentz, Jepsen, Pedersen, et al., 2017;), (Cruise & Becerra, 2018)
(Morgan & Hayward, 1988; Nielsen et al., 2015),

48. @iaedp
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 Given the hypothesized clinical potential for Alexithymia and
interoception , So Alexithymia and interoceptive training, assessing the
evidential basis of both role in autism and ED is crucial.
 If future research shows the alexithymia hypothesis to be correct, the
diagnostic criteria for autism may require revision. If it is found that
individuals with autism, but without alexithymia, exhibit no emotional
impairments, problems of emotion processing (for example, a lack of
empathy and impaired recognition of emotion in others) should no
longer be considered diagnostic markers of autism.
 The trend toward amalgamating the social and emotional symptoms of
autism may need to be reversed—under the hypothesis that social and
emotional impairments should be viewed as distinct, with autism being
associated with the former, but not the latter

49. @iaedp
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 As our understanding of autism and eating disorders grows and
the evidence that autistic traits appear in early childhood prior
to the eating disorder (Solmi et.al., 2020))
 There is opportunity for prevention and early intervention.
 Treating disordered eating in autistic people early
 Implementing support systems that are tailored to the needs of
autistic people (i.e., neurodiversity-affirming care) is key.
 Delivering psychoeducation education and
training to caregivers and professionals who engage with
autistic people (e.g. school wellbeing teams), will be an
important factor in helping to prevent the occurrence of eating
disorders in autistic people

50. @iaedp
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 Identification the overlap between autism, ED, and delayed
diagnosis indicates that autism should be screened for ED
individuals .
 Exploring whether autism could be a precursor to eating
pathology in order that more effective treatment alternatives
and mitigation strategies may be implemented.
 The mediating effect of alexithymia between autism and ED
symptomatology suggests that these individuals may
additionally benefit from treatment targeted toward improving
the social and emotional deficits in autistic individuals
 New therapeutic approaches and interventions that
incorporate emotional awareness merit further research, with
the potential to mitigate ED symptomatology and improve ED
recovery rates within the autistic population
(Aaron et al., 2015; Bird & Cook, 2013; Milosavljevic et al., 2016).

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Prof. Heba Essawy MD.,CEDS.,
essawi_h@yahoo.com
www.heba Essawy.com