Treatment Resistant Anorexia or Asperger’s?
Complex Cases: Treatment Resistant Anorexia or Asperger’s?
Stephanie C. Holmes, MA Certified Autism Specialist and Interview
with Dr. Tony Attwood World Renowned Asperger/ASD Expert.
I recently had a wonderful opportunity to interview world renowned Asperger’s Syndrome expert, Dr. Tony Attwood who resides and practices in Brisbane, Australia, for an article in Autism Digest that was printed fall of 2014 on Spectrum Teens. Dr. Attwood and I discussed issues of growing concern in the Spectrum Teen community and concern that clinicians may not be aware of when working with this population.
Founding editor of the European Child and Adolescent Psychiatry, Professor Gillberg, said eating disorders, specifically anorexia nervosa, is a huge concern in Aspie/Spectrum females. Gillberg’s research suggests that in many cases counting calories, obsession with exercise, or foods the client will or will not eat are often part of the “restricted or repetitive pattern” criteria for ASD. Attwood said, “Traditionally, family and group therapies are the treatments for choice in typical anorexia but for a person with Asperger’s Syndrome struggling with what appears to be anorexia, these treatments simply will not work.” Gillberg’s research suggests that if a client who has been diagnosed as anorexic appears to be resisting traditional treatment, it is plausible to consider the client may have undiagnosed Asperger’s Syndrome/ASD. Therefore, one to one cognitive-behavorial therapy is more effective to break about the rules and obsessions with food or calorie counting.
It is important to note the current rate of ASD diagnosis of males to females is 10:1. Leading experts such as Attwood, Gillberg, Baker and others, believe Aspie girls are being missed and the ratio is closer to 4:1. In August of 2013, research by Autism Research Center at the University of Cambridge used MRIs to compare male and female ASD brains. Some notable results of the study include:
- “As expected the tests found that the brain anatomies of females with autism were substantially different when compared to the brains of their male counterparts. In fact a completely different set of regions were implicated in the male autism brain than in female autism brains.”
- “In terms of brain morphology, females with autism look more alike to typical developing males when compared to typical developing females.”
- “So the brain change in females [with ASD] are actually shifting toward typical developing males.”
However, just because a female may be less conspicuous in her symptomology does not mean that she struggles less in adolescence than her male counterparts. Research is showing a rise of anorexia among ASD females. With ASD there is already some sensitivities around food: to its smell, texture, color etc. However, Dt. Attwood points out that an Aspie female may have a “special or restricted interest” in food and/or calories and it could appear to be “typical anorexia” but if the anorexia seems to be treatment resistant, there is cause to think that female may have Asperger’s with a “restricted interest” focused on food. In an effort to fit in, the Spectrum female may arrive to an irrational though that if only I was thinner I would be more popular with my peer group. Dr. Attwood said, “Remember, Aspies NEVER do things in halves.” So what can begin with efforts to be thinner can quickly turn to a restrictive interest in food, calorie count, etc. To Dr. Attwood and researchers, this is a manifestation of anxiety in the form of food as a special interest. Dr. Attwood said, “Usual treatment for anorexia is group therapy or a group home or family sessions, but if the female is Aspie this style of therapy will not work and it would be easy to assume the anorexia is treatment resistant.” Spectrum females are not going to get the same help from groups because their motivation, their focus for the starvation is different than their neuro-typical peers. Dr. Attwood said if the female is on the spectrum, an individual approach to therapy with a logical cognitive- behaviorial approach is the best approach for those individuals that seem not to be responding to traditional treatment.
Another area of concern that can be quite the political hot- topic, is gender identity issues among Spectrum Teens. You may be aware there are states that have laws concerning counselors addressing gender issues with a person under the age of 18. Dr. Attwood stated that research is showing there is a high probability of gender confusion issues with Spectrum Teens but it is qualitatively different than what we tend to think of as clinicians as “gender issues.” Because persons on the spectrum tend to be isolated and rejected by their peers, spectrum teens are at higher risk for clinical anxiety, depression, and self –esteem issues. Females on the spectrum tend to be bullied or humiliated by NT female peers. As discussed before, one option might be to become thinner and develop the restrictive interest in food as a way to “fit in”, but if the spectrum does not seem to be able to fit in she may think, “If I were a boy I would not be bullied so much if I could just be a boy.” Remember, the ASD female brain tends to be wired more like a neuro-typical male and she finds it easier to fit it and socialize with males instead of understanding the fickle nature of NT females. Spectrum males are in part also bullied, teased, harassed most by NT males. Spectrum males tend to find it easier to find acceptance with NT females. These spectrum males may develop a restricted interest in all things female believing “If I became a girl I would be more popular and have better social skills.” Dr Attwood encourages clinicians, “Be aware that there are different pathways to the same profile. See if the Aspie teen may believe that if they change their gender or identity it would solve all of their social problems.” So it is of great concern that spectrum teens tend to be naïve, tend not to understand who can be trusted, and if a peer group such as a gay/lesbian/transgender group were more accepting of them it would be easier for them to believe that they too have “gender confusion.” The motivation and treatment is again logical, cognitive style therapy to help the Spectrum teen identity irrational thoughts about changing gender to solve all social problems.
Spectrum persons tend to realize they are different and aware of their social difficulties in adolescence. Adolescence is a challenging time whether or not you have Autism Spectrum Disorder/Asperger’s, but Spectrum teens certainly have a few more challenges to face during this already tumultuous stage of life. Dr. Attwood stated, “First of all, we must remember that those with Asperger’s (ASD) do not have an illness or disease from which they suffer. There are not stomach aches or headaches or physical symptoms as such to cause suffering. Those with Asperger’s {ASD} suffer most because of peer groups around them. Neuro-typical teenagers are toxic creatures. Teenagers are toxic to mental health. The suffering endured is not because of Asperger’s {ASD} it is because of the attitude and degradation of others in the peer group.”
Spectrum teens find solace and relief from anxiety in their restricted or sometimes called “special interest.” Females tend to be more aware of their social difficulties and confusion and may act out with anorexic behaviors, may have gender identity issues, or suffer in silence. Barabara T. Doyle wrote about dealing with dangerous special interests for John Hopkins School of Education: http://education.jhu.edu/PD/newhorizons/Exceptional%20Learners/Autism/Articles/Working%20with%20Restrictive%20and%20Repetitive%20Interests/. If another person becomes an unhealthy object of an Aspie’s special interest such as a romantic interest there may be reason to be concerned.
Females may be more prone to Jennifer O-Toole, speaker and author, gives warning that Aspie females are more likely to be involved in a relationship of domestic violence. If the Aspie female wants to fit in and is desperate to find a boyfriend for some means of acceptance, she is susceptible for find Mr. Wrong and getting involved in a dangerous dating situation with her naivety and lack of perception of danger. Jennifer said to therapists, “If you have a female client who has struggle with or struggles with anorexia, and has a history or violent or abusive dating relationships, and has clinical anxiety or depression, you may want to consider she has Asperger’s syndrome.”
As American therapists we certainly need to abide by criteria of the DSM-5 for diagnosis, but experts around the world who still use the terminology “Asperger’s” are providing excellent research materials to help identify these individuals so that we can give them the best care and treatment. As Christian therapists we need to educate our community and churches about accepting people with differences such as Asperger’s/ASD so that the church/Chistian community can be a healing balm to those who not suffer with ASD but suffer from rejection and isolation in the world.
***This article appears in the soon to be released book by Stephanie C. Holmes Confessions of a Christian Counselor: How Infertility and Autism Grew my Faith. To be released by Highway51 Publishers in Fall of 2015.