Neurodivergence and eating disorders: an integrative view
It is quite common to encounter cases of people with more than one mental health diagnosis (comorbidity), and also some who exhibit characteristics of different neurodivergent conditions, such as autism or ADHD. Unfortunately, these latter cases often go undetected initially and may not be diagnosed until adulthood. In this article, we aim to explore which behaviors can predispose a neurodivergent person to be more vulnerable to developing an eating disorder (ED), what consequences this can have for the individual , and what self-regulation strategies can be helpful.
This relationship between neurodivergence and eating disorders is increasingly studied and taken into account in the approach to an eating disorder, since it implies greater complexity in its treatment , as it involves aspects of the general functioning and human relationships of the affected person.
We will deal here with the overlap between eating disorders and autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD).
Autism and anorexia nervosa
It is estimated that 1% of the general population has an autism spectrum disorder (Zeidan et al., 2022) and that, of these, 4% receive a diagnosis of eating disorder (ED), mainly anorexia nervosa.
Between 20 and 30% of people with anorexia nervosa receive a diagnosis of autism. It's worth noting that current autism criteria are much broader than they were originally, taking into account aspects that were previously overlooked.
Autism, therefore, is diagnosed especially in association with cases of anorexia nervosa (especially in women), and ARFID (avoidant and restrictive eating disorder with an emotional basis) (Schöder et al., 2023).
The connection in the symptomatology is found in the following aspects:
- Feeding problems in childhood : difficulties introducing or expanding the variety of foods, preferences for certain textures, colors, or smells, or for eating with specific utensils. Although this is a behavior that any child can exhibit and that usually decreases over time, it is more frequent, more pronounced, and more persistent in autistic individuals.
- Obsessive tendencies and ritualized behaviors : express the need to create a predictable and controlled environment.
- Concrete, inflexible and extremist thinking : makes it difficult to find alternatives and see the whole of a situation, although it makes it easier to detect details in which they can get "stuck".
- Problems recognizing, expressing, and managing emotions : difficulty conveying them in words and a more restricted emotional attunement. Also, difficulties grasping subtle aspects of language such as double meanings, metaphors, or facial expressions, which complicates social interaction. These difficulties can generate distress that sometimes manifests as self-harming behaviors, using physical pain as a means of release rather than through verbalization.
- Food restriction : the most frequent symptom in autistic individuals. For this reason, anorexia nervosa and ARFID are the most commonly diagnosed eating disorders in this population, although binge eating and purging also occur. Some people don't eat not because they want to lose weight, but because they don't perceive hunger and satiety cues , even forgetting when they should eat. Weight gain can also occur if the diet is limited to high-calorie and highly gratifying foods (rich in fats or sugars).
ADHD, bulimia, and binge eating disorder
Combined ADHD is more similar to bulimia or binge eating disorder than to restrictive eating, as they share impulsivity and often underlying anxiety . In predominantly inattentive ADHD, which manifests less dramatically, diagnosis can be delayed, especially if it occurs in a context of restrictive eating and weight loss. In these cases, because cognitive abilities are affected, the child or adolescent may experience academic difficulties or be labeled as lazy if ADHD is not detected.
Symptoms of impulsivity related to food (self-induced vomiting, binge eating), as seen in purging anorexia, bulimia nervosa, or binge eating disorder, although less frequent, can also occur in autistic individuals. These cases are often associated with borderline personality disorder (characterized by emotional instability and impulsivity in relationships). This co-occurrence is more common in women.
The relationship between ADHD and eating disorders
The importance and difficulty of connecting the dots
Individuals with autistic traits who reach adolescence or adulthood without a diagnosis often seek professional help indirectly: either for another mental health problem (anxiety, depression, eating disorder) or due to a persistent feeling of maladjustment to their environment. For example, they may have difficulty forming or maintaining friendships, remaining in social situations for extended periods, completing lengthy tasks, or not sharing others' sense of humor because they don't understand certain jokes or double meanings.
It's not uncommon for an autism diagnosis to be considered when a previous diagnosis doesn't fully improve . To determine this, it's essential to investigate whether the symptoms were present since childhood, that is, whether they are part of their personality. For example, when a person with anorexia experiences a decrease in restrictive behaviors or hyperactivity, but persistent low emotional tone, feelings of inadequacy, difficulties socializing and communicating, and challenges managing negative emotions, it's necessary to consider the possibility of autistic traits.
Furthermore, autism tests were designed based on the most evident cases in males. Since autism in boys tends to have more behavioral manifestations and, therefore, scores higher, the same tests in females may fall below the cutoff point. In this sense, it would be necessary to develop versions adapted to this reality, more sensitive to detecting autism in females.
Therefore, a clinical diagnosis by a professional experienced in neurodivergence is essential. Specifically, it is necessary to clarify whether the symptoms (or some of them) have been present since childhood, or whether they have developed or appeared during puberty and adolescence. It is also important to determine whether they are more consistent with autism, the emotional difficulties associated with eating disorders, or another mental health condition. Often, a longer period of observation and treatment is needed to determine the cause.
Neuropsychological tests , which analyze attention, memory, intelligence, spatial perception, and other aspects, are also useful for refining the diagnosis, although they are not infallible. These tests should be administered by a specialized professional, ideally a neuropsychologist. Therefore, it is advisable that these complex cases be addressed by a multidisciplinary team.
Adults without a prior autism diagnosis are more prone to depression, anxiety, and stress, and in the case of children and adolescents, behavioral problems that can lead to substance abuse. They may also seek relationships with clearer communication styles, although this sometimes involves abruptness or less emotional attunement, which can pose a risk of psychological or sexual abuse.
What strategies can help?
Sensory rest
Autistic people often need stimulus-free spaces to "recharge their batteries," especially after prolonged social exposure (school trips, group meals, work meetings).
Just as taking breaks during class or having small tasks that allow them to move around can help a person with ADHD maintain their attention longer, sensory breaks help a person with autism stabilize. In fact, this is helpful for everyone, but it's even more crucial for autism to prevent burnout. It's important to remember that both diagnoses (autism and ADHD) often overlap, since they share the same underlying cause: a different developmental stage of the nervous system.
Autistic people, like people with eating disorders, need support and help to find strategies that work best for them to develop in their social interaction and other areas where they struggle.
There are some aspects that may be key for people with autism who have an eating disorder:
Self-awareness
Recognizing and understanding one's own feelings, behaviors, limitations, and strengths. Accepting oneself despite differences from societal standards.
Often, when a person learns they have a neurodivergent diagnosis, it helps them understand many aspects of their life that were previously inexplicable and caused them suffering and distress. Knowing this is a step toward self-awareness, self-acceptance, and adaptation to their environment.
This aspect is relevant because it is about finding the fit in how one is, instead of how one would like to be or how one thinks one should be.
Communication and social skills
It's important for everyone to find a way to express what they want, even if they don't quite know how and the words fail them. Language isn't the only way. There are different techniques and methods (visuals, music, etc.) that each person or their environment can use and adapt to facilitate communication in ways that aren't solely verbal.
Leire Martín Curto
Seek support and build a network
It is essential to have reference professionals who understand the diagnoses, as well as associations of people with autism and their families, as well as those for eating disorders, which provide support, information, awareness and even job guidance, contributing to the development of a full life.
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