Francesca Solmi, Ph.D., discusses the intricate link between autism and eating disorders. She outlines common eating disorders, noting their overlapping symptoms and similarities to autism traits. The speaker explores potential mechanisms for the connection between eating disorders and autism, including communication difficulties, sensory sensitivities, and emotion regulation. Solmi emphasizes Avoidant/Restrictive Food Intake Disorder (ARFID) and its relevance to autism, underscoring the need for more research and services for this often overlooked condition. The presenter considers future research directions before the Q&A.  

Handouts are online HERE

In this webinar:

1:30 – Common eating disorders
8:00 – Autism and eating disorders
11:00 – Trajectories of autistic traits and eating disorders
20:00 – Potential linking mechanisms
28:00 – Emotion regulation
34:50 – Avoidant/Restrictive Food Intake Disorder (ARFID) and Autism
40:00 – Future research
42:00 – Q&A

Overview of Eating Disorders 

Solmi defines eating disorders as severe psychiatric conditions that typically emerge in early to mid-adolescence. She describes common eating conditions, including Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, and OSFED (Other Specified Feeding or Eating Disorder), highlighting the significant symptom overlaps across conditions (1:35).

• Anorexia Nervosa – frequently the youngest age of onset. Characterized by an intense fear of weight gain, extreme dietary restriction, and often low body weight. Some individuals may also engage in bingeing and purging.
• Bulimia Nervosa – slightly later onset and involves episodes of binging followed by compensatory behaviors like self-induced vomiting or excessive exercise.
• Binge Eating Disorder – the most recently recognized diagnosis. It involves bingeing without compensatory behaviors, often accompanied by feelings of shame or guilt.
• OSFED (Other Specified Feeding and Eating Disorder) is a residual category for individuals whose symptoms don’t fully meet the criteria for other diagnoses. 

The speaker emphasizes the severity of these conditions, noting their association with higher mortality rates (5:00). Despite this, eating disorders are often under-researched compared to other mental health disorders. She also notes their high prevalence in girls and women, suggesting underdiagnosis in men (6:30).  

The Link Between Autism and Eating Disorders 

Solmi discusses the connection between autism and eating disorders. A study by Westwood and colleagues revealed elevated autistic traits in people with anorexia nervosa. Similarly, people with autism and anorexia nervosa mentioned rigidity or rules, intense interests, difficulties recognizing hunger, and social difficulties (8:00). A significant challenge in this research, the presenter explains, is distinguishing between pre-existing autistic traits and those that may be mimicked by severe malnutrition in anorexia nervosa. 

Autism Spectrum Disorder in Anorexia Nervosa: An Updated Literature Review (Westwood et al., 2016)

Research on Autistic Traits and Disordered Eating Trajectories

Solmi presents findings from a study investigating whether autistic traits were present before the onset of disordered eating behaviors (11:00). Researchers found that children who later developed disordered eating behaviors exhibited higher levels of autistic traits at age seven, and these differences persisted throughout adolescence. The speaker asserts that these findings suggest autistic traits may precede the onset of disordered eating (17:00). The study also revealed that more severe eating disorder symptoms correlated with higher autistic trait scores from age seven onwards, indicating a strong association with more severe presentations of eating disorders.

Trajectories of autistic social traits in childhood and adolescence and disordered eating behaviours at age 14 years: A UK general population cohort study (Solmi et al., 2020)

Potential Mechanisms Linking Autism and Eating Disorders 

The presenter explores several mechanisms as potential links between autism and eating disorders. For example, as friendships become more important in adolescence, struggles with social interaction can exacerbate mental health difficulties, with eating disorders potentially serving as a coping mechanism. Children with social communication difficulties may also be more susceptible to bullying, which can lead to internalized weight-stigmatizing thoughts and behaviors like dieting (20:00). Young people with autism often exhibit more sedentary behaviors compared to their peers, which can increase BMI and vulnerability to weight-based stigmas (23:00). 

Emotion regulation difficulties are also common in both autism and eating disorders. Solmi outlines a recent study showing that individuals who later developed anorexia nervosa symptoms exhibited less improvement in emotion regulation skills from early to mid-childhood compared to their peers, where differences emerged around age five (30:00). Further, in girls, social cognition explained around half of the association between emotion regulation difficulties and disordered eating. The association in boys was less clear, likely due to smaller sample sizes (35:00).

The presenter notes that sensory sensitivities, a core aspect of avoidant/restrictive food intake disorder (ARFID), are frequently reported by people with anorexia nervosa. For example, in a qualitative study on autism and anorexia in women, emerging themes included difficulty with sensory sensitivities, social interactions and relationships, and challenges with emotions (33:00). 

A mixed-methods approach to conceptualizing friendships in anorexia nervosa (Datta et al., 2021)

Autism Spectrum Disorder and Obesity in Children: A Systematic Review and Meta-Analysis (Sammels et al., 2022)

Emotional dysregulation in childhood and disordered eating and self-harm in adolescence: prospective associations and mediating pathways (Warne et al., 2022)

“For Me, the Anorexia is Just a Symptom, and the Cause is the Autism”: Investigating Restrictive Eating Disorders in Autistic Women (Brede et al., 2020)

Avoidant/Restrictive Food Intake Disorder (ARFID) and Autism

Solmi discusses ARFID, a disorder now included in the eating and feeding disorder family, noting its relevance to autism. Its three main aspects include limited interest in food, sensory sensitivities (e.g., avoiding specific foods due to texture), and concerns about adverse consequences from eating (34:50). The speaker emphasizes the limited epidemiological research on ARFID, the lack of services (especially for people who are not severely underweight), and the need for more studies to understand its prevalence, risk factors, and effective treatments (37:00).

Future Research Directions 

According to the presenter, future research should aim to understand the complex links between autism and eating disorders more comprehensively. Key areas of investigation include the connections between sensory sensitivities and ARFID, gender differences in the association of autistic traits and eating disorders, links between other autistic traits and different eating disorder presentations, physiological factors like the gut-brain response, and age of autism diagnosis in those with and without eating disorders. These avenues of research, Solmi asserts, will improve diagnostic tools and help to develop better prevention and care strategies (40:00). The speaker summarizes main points before the Q&A (42:20). 

Jennifer Frankovich, MD, MS, dives into the intersection of infection, inflammation, and mental health. She discusses the increase in recognition of this critical overlap over the last decade, highlighting how systemic inflammatory conditions have the highest rate of co-occurring psychiatric disorders. The speaker outlines ten inflammatory diseases that frequently co-occur with mental health conditions, including spondyloarthritis, psoriasis/psoriatic arthritis, Behçet’s Syndrome, Sjögren’s disease, Scleroderma, CNS Vasculitis, Sydenhams’ Chorea, and Lupus. Frankovich underscores the connection of Streptococcal infections to many of these inflammatory conditions, noting their similarities to PANS and challenges with diagnosis. She provides thanks and acknowledgments before the Q&A. 

This is a follow-up to our June 12, 2024 webinar featuring Dr. Jennifer Frankovich, Ayan Mondal, Ph.D., and Noor A. Hussein, Ph.D.

In this Webinar

1:20 – Inflammation and mental health
3:50 – Spondyloarthritis (SpA)
11:00 – Psoriasis/Psoriatic Arthritis
16:05 – Behçet’s Syndrome
19:25 – Brain parenchymal disease
21:15 – Non-parenchymal disease
22:25 – Sjögren’s disease
24:05 – Scleroderma
25:50 – CNS Vasculitis
26:25 – Sydenhams’ Chorea
37:00 – Erythema Marginatum
38:50 – Strep infections and mental health
42:00 – Lupus
44:55 – Q&A

Inflammation and mental health

Over the last decade, recognition of the overlap between rheumatological/inflammatory disorders and mental health conditions has significantly increased. Frankovich notes common inflammatory diseases that co-occur with psychiatric symptoms, including those caused by small-vessel vasculitis, autoimmune encephalitis, basal ganglia inflammation, and white matter inflammation (1:20). Most commonly, she continues, systemic inflammatory conditions like psoriasis/psoriatic arthritis, and irritable bowel syndrome (IBS) have the highest rates of co-occurring psychiatric disorders (3:30). She outlines ten (10) specific disorders, how they present, and how clinicians/practitioners can test for them.

The odd couple?—Hardly: The emerging overlap between rheumatology and psychiatry (Taylor & Jain, 2017)

Spondyloarthritis 

Spondyloarthritis (SpA) can cause microscopic spinal inflammation that is not often perceptible on imaging until decades later. It is characterized by pain and stiffness in the morning and after prolonged stationary positions. Frankovich explains that 40% of patients with SpA also experience depression, anxiety, fatigue, and brain fog and that adults with SpA have a higher prevalence of OCD, anger/hostility, and deliberate self-harm versus controls (3:50). The speaker notes that children with psychiatric diagnoses may not be able to articulate pain and stiffness, so practitioners must look for clues such as stiffness walking, axial and peripheral stiffness, iliac pain and tenderness, and specific foot pains. Psoriasis and bowel inflammation also commonly co-occur with SpA. Frankovich underscores the high heritability of SpA and suggests observing parental symptoms when diagnosing children (7:15). 

Psoriasis/Psoriatic Arthritis

Psoriasis and psoriatic arthritis have significant overlap with psychiatric disorders, especially bipolar, depression, and anxiety. The speaker explains that pain from arthritis can seem out of proportion, so patients are often dismissed. Frankovich notes specific ultrasounds that can be used to identify inflammation in discrete areas of the body and reiterates how psychiatric conditions may keep patients, especially children, from complaining of their pain, making a diagnosis even more challenging (11:00). Common sites for psoriasis include behind the ears, on the scalp, around the belly button. She warns against mistaking Onycholysis for fungal nail infections and notes that streptococcal infections can trigger arthritis flares (13:35). 

Behçet’s Syndrome

The speaker describes Behçet’s Syndrome as a multisystem inflammatory disease where 10% of patients have neurological diseases perceptible on an MRI and 40% have psychiatric disorders. Other symptoms can include recurrent oral ulcers, ocular inflammation in the anterior portion of the eye, and potential scarring from genital ulcers. Behçet’s Syndrome is a type of transient arthritis where flareups, often triggered by intense immune responses to infection, can last from one to three weeks (16:05). Frankovich notes that when vascular inflammation is present in both arteries and veins, this nearly always indicates Behçet’s Syndrome. Pathergy, or blistering at the blood draw site, is also a strong indicator (18:25). 

Brain parenchymal disease

Brain parenchymal disease (BPD) is characterized by a subacute onset of multi-focal inflammatory legions, which an MRI can miss if it is not conducted at the time of a new deficit. In many cases, the MRI reflects non-specific white matter changes that do not rule out BPD in and of themselves. Some patients also suffer from headaches, behavior changes, and cognitive dysfunction, which can lead to temporary encephalopathy, seizures, and psychosis. The presenter underscores the importance of early diagnosis and treatment but notes that BPD is difficult to diagnose because legions are temporary and appear in different places each time (19:25). 

Non-parenchymal disease

Non-parenchymal diseases involve the brain’s venous systems. Cerebral venous thrombosis, or severe headaches, must be assessed using imaging that highlights the venous system (e.g., MRV). Non-parenchymal diseases often co-occur with fibromyalgia (18 – 37%), parietal cell autoantibodies, vitamin deficiencies (especially B,) and bowel ulcers or IBS (21:15). 

Sjögren’s disease

Frankovich defines Sjögren’s disease as a systemic rheumatologic condition that often presents with dry eyes and mouth and a lot of autonomic nervous system dysfunction such as altered vascular tone, esophageal contractility (trouble swallowing), cardiac rhythm abnormalities, and neuropathic symptoms (i.e., burning, tingling, or numbness). Co-occurring psychiatric disorders make it challenging to self-advocate. The speaker suggests running a mucosal biopsy of the lip to assess salivary gland inflammation if Sjögren’s disease is suspected (22:25). 

Scleroderma

Scleroderma is a systemic sclerosis that causes widespread vascular dysfunction and progressive fibrosis of the skin and internal organs. Over many years, the speaker explains, a person’s skin starts to harden. Early signs in children include Raynauds (cold, white hands) and abnormal nail fold capillaroscopic. She highlights that manifestation may precede the full disease by years, so it is critical to follow patients closely (24:05). 

Personality structure disturbances and psychiatric manifestations in primary Sjögren’s syndrome (Drosos et al., 1989)

CNS Vasculitis

CNS vasculitis is a very rare type of inflammation focused on the brain. It is perceptible on MRI scans and should be considered when children present with new-onset headaches and behavior changes (25:50). 

The spectrum of CNS vasculitis in children and adults (Twilt & Benseler, 2012)

Sydenhams’ Chorea

Sydenhams’ Chorea (SC) presents with three critical components: emotional lability, hypotonia (weak muscles), and chorea (involuntary, brief, random, and irregular movements of the limbs and face). In children, this can look like continuous restlessness (26:25). Frankovich explains that accompanying psychiatric symptoms are similar to what we see in PANS. For example, 60% of patients with SC have OCD at onset, and 100% have it at relapse. Other symptoms include outbursts of inappropriate behavior or mismatched emotions (easy crying or inappropriate laughing), irrational fears that can lead to delusions, anxiety, personality changes, and night terrors (28:08). Other presentations include difficulty keeping arms up or hyperactive reflexes (33:40). 

The presenter notes that the line between what is and is not SC is very blurry, making it hard to detect and diagnose. One of the earliest studies (1926) notes that, in children, nuanced chorea is always Sydenhams, so practitioners should always treat for strep infection and clear it out of the house. According to the study, emotional lability is the most constant observation, along with extreme personality changes where individuals become aggressive and irritable, which is very similar to how PANS presents (30:00). 

Children often cover up their chorea, so clinicians must actively look for muscle use abnormalities. Simple tests for chorea include the milkmaid’s grip and darting tongue. Because psychiatric symptoms like OCD can start two to four weeks before chorea, children who present with acute-onset OCD should be re-evaluated over at least one month (31:25). The onset of chorea can occur anywhere between one and eight months after a strep infection, meaning that ASO and DNASE titers may be normal during assessments (33:40). 

The presence of acute rheumatic fever can also support an SC diagnosis, but it is not necessary. However, the speaker warns that mild cases of SC without other manifestations of acute rheumatic fever may be mistakenly ascribed to behavior or emotional disorders, restlessness, or clumsiness. She reiterates the need for careful evaluation (36:10). 

Neuropsychiatric Aspects of Chorea in Children (Ebaugh, 1926)

The Prevalence of Neuropsychiatric Disorders in Sydenham’s Chorea (Ridel et al., 2010)

Obsessive compulsive behavior, hyperactivity, and attention deficit disorder in Sydenham chorea (Maia et al., 2005)

High prevalence of obsessive-compulsive symptoms in patients with Sydenham’s chorea. (Swedo et al., 1989)

Obsessive-Compulsive and Related Symptoms in Children and Adolescents With Rheumatic Fever With and Without Chorea: A Prospective 6-Month Study (Asbahr et al., 1998)

Sydenham’s Chorea: Physical and Psychological Symptoms of St Vitus Dance (Swedo et al., 1993)

The Emotional Correlates of Sydenham’s chorea (Freeman et al., 1963)

Mental Symptoms of Acute Chorea (Diefendor, 1912)

Rheumatic fever (Stollerman, 1997)

Erythema Marginatum 

Erythema Marginatum is a rash or skin lesion that occurs in SC and is brought out with heat (warm blankets or bath). Frankovich describes a case study of a 16-year-old with a long history of regressive behavior deterioration. He was initially diagnosed with SC; however, due to a lack of valve involvement, the diagnosis was removed. When he later presented with catatonia, clinicians wrapped him in warm blankets for 10 – 20 minutes and then observed his torso and limbs for rash patterns. The speaker notes that Erythema Marginatum patterns change every few minutes and that no other condition presents with such a rash (37:00). 

Streptococcal infections, inflammation, and mental health

A recent population-based study on the association of streptococcal infection and mental disorders found the primary outcome of strep infections was a diagnosis of mental disorders, OCD, or tics (38:50). The speaker says it can be difficult to know if strep played a role in any child’s behavior, so we must rely on epidemiologists continue educating practitioners about the link between strep and mental disorders, especially OCD. 

A smaller study that compared school strep swabs to behaviors found a high correlation between positive strep throat cultures and the presence of tics, adventitious movements, and problem behaviors. Further, if the strep was recurring, the risk for abnormal movements was increased (40:00). Many animal models have also shown this correlation. 

 Association of streptococcal throat infection with mental disorders (Orlovska et al., 2017)

Relationship of Movements and Behaviors to Group A Streptococcus Infections in Elementary School Children (Murphy et al., 2007)

CNS Autoimmune Disease after Streptococcus Pyogenes Infections: Animal Models, Cellular Mechanisms and Genetic Factors (Cutforth et al., 2016)

Lupus 

Lupus, though a common condition, is relatively rare in children. However, 25% of children with Lupus also have neuropsychiatric symptoms such as headaches (66%), psychosis (36%), and cognitive dysfunction (27%). Similar to PANS, Lupus patients commonly have arthritis, small vessel vasculitis, and high immune complexities. They are also 10 – 15 times more likely to have OCD compared to patients without Lupus (42:00). 

Resources

Frankovich thanks viewers and acknowledges research contributors. For more information on her research, visit med.stanford.edu/PANS. During the Q&A (44:55), the speaker answers questions about diagnosis, overlapping conditions, and much more.

Originally posted on October 1, 2024