Cognitive Behavioral and Cognitive Remediation Strategies for Managing Co-Occurring Anorexia Nervosa and Elevated Autism Spectrum Traits

Figures & data

Figure 1 Study selection process.

Table 1 Characteristics and Main Results of the Included Studies

Study	Participants with AN				Treatment or Study Setting	Measures	Main Findings
	Individuals with High ASD Traits or Diagnosed ASD (n)	Controls with Low ASD Traits (n)	Sex	Age			Measured with Performance-Based Test	Measured with Self-Report or Clinical Follow-Up
Adamson et al., 2018^Citation37	21 with ASD traits (measured with AQ-10)	44	All females	18–63 years, mean age 25.5 year	Individual CREST (8 sessions)	Three self-report questionnaires focusing social anhedonia, alexithymia, and MR (subscales: ability to change, importance to change).	N/A	Ability to change increased (time F(1,37) = 11.27, p < 0.01; time x ASD F(1,27) = 0.02, p = 0.88) and alexithymia (time F(1,47) = 6.84, p = 0.01; time x ASD F(1,34) = 0.10, p = 0.75) improved. Importance of change (time F(1,42) = 0.04, p = 0.84; time x ASD F(1,32) = 1.00, p = 0.32) or social anhedonia did not improve time (F(1,46) = 0.79, p = 0.38; time x ASD F(1,33) = 2.99, p = 0.09). There was no interaction between ASD traits and any of the measured outcome.
	21 with ASD traits (measured with AQ-10)	45	All females	18–53 years, mean age 25.8 years	Group CREST (5 sessions)	Three self-report questionnaires focusing social anhedonia, alexithymia, and motivation.	N/A	Ability to change increased (time F(1,48) = 4.57, p = 0.04; time x ASD F(1,34) = 2.08, p = 0.16). Social anhedonia (F(1,51) = 0.87, p = 0.36; time x ASD F(1,36) = 0.27, p = 0.61), alexithymia (F(1,48) = 1.67 p = 0.20; time x ASD F(1,34) = 0.85, p = 0.36), or importance to change (F(1,49) = 2.81, p = 0.10; time x ASD F(1,35) = 0.68, p = 0.42). did not improve. There was no interaction between ASD traits and any of the measured outcome.
Babb et al., 2021^Citation45	15 individuals with diagnosed ASD	0	All females	23–58 years, mean age 32.60 years	Retrospective interview about treatment experiences.	Qualitative interview	N/A	Participants described that they had had difficulties in CBT because they viewed they did not have the skills needed for benefiting from CBT. Participants described that they perceived group therapy as challenging due to their social difficulties.
Dandil et al., 2020a^Citation44	25 individuals with high ASD traits (measured with AQ-10)	35	All females	Mean age 23.9 years	Individual CRT (8–10 sessions)	Two performance-based test (ROCF, The Brixton Test)	Among individuals with high ASD traits, cognitive flexibility improved (t(24) = 5.3, p < 0.001) but central coherence did not (t(23) = - 1.9, p = 0.06). Among individuals with low ASD traits, cognitive flexibility improved (t(35) = 6.74, p < 0.001) but central coherence did not (t(34) = - 1.44, p > 0.05).	N/A
Dandil et al., 2020b^Citation34	1 individual with diagnosed ASD	0	Female	21 years old	Individual CRT (13 sessions)	Three self-report questionnaires (DFlex, EDE-Q, MR), two performance based-test (ROCF, The Brixton Test)	No improvement in cognitive flexibility or central coherence.	Improvement of eating disorder symptoms, cognitive flexibility, central coherence, and ability to change.
Giombini et al., 2022^Citation42	18 individuals with high ASD traits (measured with SRS-2)	62	75 females, 5 males	10–18, mean age 14.49 year	Individual CRT	Four self-report questionnaires (DFlex, EDE-Q, MR (subscales: ability to change, importance to change), RCADS), three performance based-test (ROCF, The Brixton Test, WCST)	Cognitive flexibility improved, but in WCST, follow-up analysis showed that only older age group with low ASD traits showed improvement (time: F(2,152) = 6.76, p < 0.002, n^2p =0.082; time x treatment group x ASD: (F(2,152) = 3.45, p = 0.034, n^2p = 0.043), and in Brixton, group with low ASD traits showed greater improvement that group with high ASD traits (time: F(2,152) = 32.00, p < 0.000, n^2p = 0.296; time x treatment group x ASD: (F(2,152) = 4.00, p < 0.020, n^2p = 0.050). Central coherence was improved; there was no significant difference between high or low ASD trait groups (time: F(2,158) = 6.874, p < 0.001, n^2p = 0.08).	No improvement DFlex, MR (ability to change and importance of change). Eating disorder symptoms improved (p < 0.000) and there was no interaction between ASD traits and eating disorder symptoms improvement.
Kinnaird et al., 2019^Citation22	9 individuals with diagnosed ASD, 4 with high ASD traits (measured with AQ-10 and ADOS)	0	11 females, 2 non-binary	Mean age 28.46 years	A retrospective interview about treatment experiences	Qualitative interview	N/A	Participants described that treatment should be adapted to individuals with AN and ASD. and that it is important to recognize the role of underlying ASD traits in AN.
Tchanturia et al., 2016^Citation43	14 individuals with high ASD traits (measured by AQ-10 or ADOS)	21	All females	Mean age 26.2 years	Group CRT (6 sessions)	Two self-report questionnaires (DFLex, MR (subscales ability to change and importance to change)	N/A	Among the group with high ASD traits, there was no improvement in any of the measured areas (cognitive rigidity: d = 0.0, p = 0.905; attention to detail d = 0.1, p = 0.702; importance to change: d = 0.2, p = 0.427; ability to change: d = 0.2, p =0.389). Among the group with low ASD traits, cognitive flexibility and ability to change improved significantly, while central coherence and importance to change did not (cognitive rigidity: d = 0.5, p = 0.007; attention to detail d = 0.4, p = 0.053; importance to change: d = 0.1, p = 0.450; ability to change: d = 0.5, p =0.004).
Tchanturia et al., 2021^Citation46	7 individuals with high ASD traits (measured by AQ-10)	16	All females	18–60 years, mean age 28.2 years	One workshop focused on sensory processing	A self-report questionnaire before and after workshop (focusing on sensory wellbeing) and after workshops also a self-report qualitative feedback questionnaire	N/A	Among individuals with high ASD traits, sensory confidence was increased (d = 1.07, p = 0.039), whereas sensory awareness and strategies to enhance sensory wellbeing did not improve (d = 0.86, p = 0.066; d =0.64, p = 0.131, respectively). Among individuals with low ASD traits, sensory confidence (d = 1.55, p = 0.001), sensory awareness (d = 1.04, p = 0.004), and strategies to enhance sensory wellbeing increased (d = 1.62, p = 0.001).
Treasure et al., 2019^Citation47	1 individual with ASD traits defined by clinical history	0	Female	17 years old	MANTRA with a special focus on social difficulties	Clinical follow-up	N/A	Symptoms of eating disorder and social difficulties improved to some degree.

Abbreviations: ADOS, autism diagnostic observation schedule; AN, anorexia nervosa; ASD, autism spectrum disorder; AQ-10, Autism Spectrum Quotient 10; CBT, cognitive behavioral therapy; CREST, cognitive remediation and emotional skills training; CRT, cognitive remediation therapy; DFlex, Detail and Flexibility Questionnaire; EDE-Q, Eating Disorder Examination Questionnaire; MANTRA, Maudsley anorexia nervosa treatment for adults; MR, motivational ruler; RCADS, The revised child anxiety and depression scale; ROCF, The rey–osterrieth Complex Figure; SRS-2, Social responsiveness scale −2.

Table 2 Treatment Adaptations for Individuals with Anorexia Nervosa and Autism Spectrum

ASD Characteristics in Individuals with AN	Possible Treatment Modifications
Difficulties in social cognition and emotion processing	● Individual CREST may improve motivation and alexithymia ● Group therapy may be challenging because of social difficulties, and extra support for participating in group therapy may be needed. Structured group discussion may however improve social communication skills ● Extra support for engaging in age-appropriate peer relationships ● In family-based treatment, the whole family may benefit from extra support for emotion regulation and emotion identification ● Modifications for communication style may be helpful
Cognitive inflexibility and rigidity	● Individual CRT may improve cognitive flexibility ● Due to more severe neurocognitive difficulties, the required length of treatment may be longer ● More understanding for cognitive inflexibility as an inherent trait ● Extra support before and during CBT in order to train skills that make it possible to benefit from CBT, eg, ability to transfer learned things to real-life situations, ability to generalize learned things
Atypical sensory processing	● Psychoeducation about sensory processing ● CBT developed for ARFID including s systematic desensitization for different tastes, smells, and textures ● Specifying the types of food which the individual has eaten and/or has not eaten before AN in order to define whether they have always avoided certain textures or tastes ● Modifications of nutrition plan, eg, striving to offer food that is bland, mild, and of soft texture ● Increasing the predictability of the offered food by not varying menus too much and providing photographs of the foods beforehand ● Modifications for treatment environment in order to decrease the sensory load

Abbreviations: AN, anorexia nervosa; ARFID, avoidant/restrictive food intake disorder; ASD, autism spectrum disorder; CBT, cognitive behavioral therapy; CREST, cognitive remediation and emotional skills training; CRT, cognitive remediation therapy.

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