Why do autistic women develop restrictive eating disorders? Exploring social risk factors Hannah Baker D.Clin.Psy. thesis (Volume 1), 2020 University College London 2 UCL Doctorate in Clinical Psychology Thesis declaration form I confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. Signature: Name: Hannah Baker Date: 19/06/2020 3 Overview This thesis seeks to understand why women with Autism Spectrum Disorder (‘autism’) are more likely to develop restrictive eating disorders (‘REDs’). Part 1 is a conceptual introduction exploring the wider topic. To start, I introduce key terms and explore current understanding of autism among females, including the notion of ‘social camouflaging’; the masking of autistic traits and imitation of social behaviours, common among autistic women. Next, I discuss issues around prevalence and diagnosis of autism among those with REDs and the experience of eating disorder treatment for autistic individuals. Finally, a comprehensive review of the literature, outlining the multiple factors which might increase the likelihood of autistic women developing REDs, is presented. Part 2 documents an empirical study investigating the specific role of social risk factors for autistic women with REDs. It is hypothesised that difficulties gaining acceptance from others increases the likelihood of autistic women to perceive themselves as inferior. Moreover, that autistic women who attempt to ‘fit in’ through social camouflaging, are more vulnerable to such risk factors. Two groups of autistic women, with and without REDs, are compared on measures of social comparison, submissive behaviour, fear of negative evaluation and social camouflaging. Autistic women with REDs are found to compare themselves as significantly more inferior than autistic women without REDs. The clinical implications of the findings are discussed. Part 3 of the thesis is a critical appraisal which describes personal reflections on the research process, the impact of the COVID-19 pandemic and suggestions for future research. 4 Impact Statement Over a third of women in treatment for restrictive eating disorders (REDs) such as anorexia nervosa, also meet criteria for Autism Spectrum Disorder (‘autism’). Despite this, current treatment guidelines, such as the National Institute of Clinical Excellence (NICE, 2017) do not include, or indeed acknowledge, autism within their recommendations. Consequently, eating disorder (ED) services in the UK currently fail their autistic clients (Kinnaird et al., 2019), who have lower recovery rates (Tchanturia et al., 2016) and worse treatment outcomes (Nazar et al., 2018). Autistic women report difficulty accessing ED treatment, a lack of recognition of their autism within ED services and poor relationships with healthcare professionals (Kinnaird et al., 2019). Furthermore, ED clinicians feel less confident supporting autistic individuals, due to a lack of clear guidance (Kinnaird, Norton & Tchanturia, 2017). At the very least, autistic individuals require evidence-based care pathways that are tailored to their specific needs, for an equal chance of recovery. It is therefore vital that commissioners and clinicians have access to a scientific evidence- base to inform how ED services can support autistic individuals effectively. This thesis falls under ‘The Study of Eating Disorders in Autistic Females (SEDAF)’, a wider project carried out by UCL and Cardiff University. SEDAF is a two-staged mixed methods study which seeks to (i) generate new understanding about REDs amongst autistic women and (ii) identify how services can adapt to become more accessible to their autistic clients. Stage one involved interviews with autistic women with anorexia, carers and healthcare professionals which informed the first data-driven model of autism-specific mechanisms underlying REDs (Brede et al., 2020). The second stage seeks to test this model and draw conclusions about specific risk and maintenance factors underlying REDs among autistic individuals. This increased 5 knowledge will enable the selection and implementation of treatments that target causal and maintaining factors specific to autistic individuals. Therefore this study exploring social risk factors, alongside the wider SEDAF project, will benefit academia, healthcare professionals and autistic service-users. The research will advance the current literature by directly testing hypotheses about the mechanisms underlying REDs among autistic women. Dissemination of this evidence will occur through academic journals, healthcare conferences and direct feedback to NHS services. In turn, this will improve how ED services engage, assess and treat their autistic patients with REDs. In the long term, this could promote development and research of novel specialist autism interventions for REDs. Most importantly, this increased understanding of REDs among autistic individuals will improve the clinical outcomes and treatment experiences for women with autism accessing ED services. 6 References Brede, J., Babb, C., Jones, C., Elliott, M., Zanker, C., Tchanturia, K., ... & Mandy, W. (2020). " For Me, the Anorexia is Just a Symptom, and the Cause is the Autism": Investigating Restrictive Eating Disorders in Autistic Women. Journal of Autism and Developmental Disorders. Kinnaird, E., Norton, C., & Tchanturia, K. (2017). Clinicians’ views on working with anorexia nervosa and autism spectrum disorder comorbidity: a qualitative study. BMC psychiatry, 17(1), 292. Kinnaird, E., Norton, C., Stewart, C., & Tchanturia, K. (2019). Same behaviours, different reasons: what do patients with co-occurring anorexia and autism want from treatment?. International Review of Psychiatry, 31(4), 308-317. National Institute for Health and Care Excellence. (2017). Eating disorders: recognition and treatment (NICE Guideline NG69). Retrieved from https://www.nice.org.uk/guidance/NG69 Nazar, B. P., Peynenburg, V., Rhind, C., Hibbs, R., Schmidt, U., Gowers, S., ... & Treasure, J. (2018). An examination of the clinical outcomes of adolescents and young adults with broad autism spectrum traits and autism spectrum disorder and anorexia nervosa: A multi centre study. International Journal of Eating Disorders, 51(2), 174-179. Tchanturia, K., Larsson, E., & Adamson, J. (2016). How anorexia nervosa patients with high and low autistic traits respond to group Cognitive Remediation Therapy. BMC psychiatry, 16(1), 334. 7 Table of Contents Part 1: Literature Review ....................................................................................................... 9 Why do autistic women develop restrictive eating disorders?............................................. 9 Exploring autism-specific mechanisms .................................................................................. 9 Introduction .......................................................................................................................... 10 Autism Specific Risk Factors for Restrictive Eating Disorders........................................... 23 Conclusion ........................................................................................................................... 45 Part 2: Empirical Paper ........................................................................................................ 60 Why do autistic women develop restrictive eating disorders?........................................... 60 Exploring social risk factors ................................................................................................. 60 Introduction .......................................................................................................................... 62 Method ................................................................................................................................. 71 Results .................................................................................................................................. 80 Discussion ............................................................................................................................ 85 Strengths and Limitations .................................................................................................... 90 Clinical Implications ............................................................................................................ 92 Future Directions ................................................................................................................. 93 Part 3: Critical Appraisal .................................................................................................... 105 Reflections on the Research ................................................................................................ 105 Introduction ........................................................................................................................ 106 Reflections on the Research Process .................................................................................. 106 Impact of COVID-19 ......................................................................................................... 114 Future Directions ............................................................................................................... 116 Appendices ............................................................................................................................ 121 Appendix 1: NHS Health