Background
Methods
Design
Participants
Data collection
Data analysis
Results
Theme | Sub-Theme | Participant endorsement |
---|---|---|
Therapist reactions to having a patient with ASD | Lack of confidence | 1, 2, 3, 4, 6, 7 |
Information seeking | 2, 4, 5, 7 | |
Diagnostic referral | 2, 4, 5, 8 | |
Specific issues in treating comorbid ASD and AN | Difficulty treating | 1, 2, 4 |
Communication problems | 1, 2, 4, 5, 6, 9 | |
Emotions | 1, 5, 8 | |
AN/ASD overlap | 1, 2, 3, 7, 8 | |
Sensory | 5 | |
Techniques used to treat comorbid ASD/AN | Patient-driven process | 1, 2, 4, 7, 8 |
Adaptations to therapy | 1, 5, 9 | |
Adaptations to communicative style | 2, 6, 9 | |
Specific modifications | 1, 4, 5, 8, 9 |
Clinician reflections on having a patient with ASD
Where the patient was exhibiting ASD traits but had no prior diagnosis, a number of clinicians suggested that they would refer the individual to a specialist ASD service for the assessment. However, there did not appear to be clear or common pathways for assessment referrals, with participants variously suggesting that they would consult a specialist registrar doctor (Participant 4), the team lead clinical psychologist (Participant 4), specialist services (Participant 5) or carrying out a brief assessment themselves (Participant 5).“So, but I don’t know a huge amount about ASD so I’d certainly find, speak to somebody that knows a bit more about it or look up something just to think about what I might need to be aware of.” – Participant 7.
Participant 8 also noted that she would wait until the patient was weight restored until she referred for a diagnosis, “because low weight can actually make it seem like they have ASD or ASD traits”.“If we’re thinking about whether someone who’s undiagnosed who may have an ASD diagnosis, I will be- along the course of therapy- thinking about whether it’s going to be helpful to pursue that or not. Of course, with some people it’s not helpful to even think about diagnosis - it’s not going to be something that they’re going to gain from it.”
Specific issues in treating comorbid ASD and AN
Participant 1 suggested that these communication problems made building a therapeutic relationship more difficult- “it’s really hard to get communication going”. Clinicians found that they had to adapt their own communication styles to meet the needs of the patient, with Participant 2 describing the need to “speak the same language as her (patient with ASD)”. Participant 6 noted the need for “clear and unambiguous instructions”, and the need to go into more detail in some cases. Participant 9 similarly highlighted that “I am very careful about the things that I say being taken literally so I might not be thinking about using context humour or metaphors…, I would be keeping it very simple”.“You listen to the way they respond, if you like, and sometimes their responses are very short compared to somebody that doesn’t have ASD. You know sometimes, you start somebody off on something and they can roll on for ages telling you about a situation. But I find with autism every time you ask for something you get a sentence back - you don’t get, sometimes it’s quite curt, you know, almost to the point of rude but not rude because that’s how they respond” – Participant 1.
Participant 3 suggested that she would try and judge to what extent the patient’s rigidity was due to their AN and could therefore be improved:“I think that the problem with eating disorders is the rigidity of it- is that patients tend to hate change, hate anything different, very rigid rules around food. And it sounds like an eating disorder but may not be, but just their [individuals with ASD] rigid rules around things. They might eat the same food every day or have three different foods that they eat and they can’t bear to try anything else, they just can’t bear it and that’s quite hard to shift.”
Whereas treatment for EDs would typically focus on changing symptoms, Participant 5 highlighted that treating patients with comorbid ASD often entailed a process of acceptance and adaptation for both the patient and the clinician:“Because there’s an element of overlap between the ASD diagnosis and the rigidity that comes with an eating disorder, it’s quite useful, at least in my head, if I can start thinking about what, where there could be some flexibility, and where there probably isn’t going to be some flexibility.”
Only one participant mentioned that individuals with comorbid ASD may have additional sensory problems that might complicate the treatment of their ED:“The other thing is difficulties with rigidity and routine and being realistic about how much flexibility you’re going to achieve with these patients. Helping people to live with the fact- in fact, helping people to accept and be ok with the fact that they have that type, have that approach to plans and routines. And that can be really helpful. And working at level of flexibility which is going to give them some movement in their life without asking too much of them.”
“She was really sensory around food and textures and so thinking about really involving the dietician carefully, and prepping the dietician and co-working with the dietician around what they’re going to suggest. So it kind of helped around those sorts of things… And then I guess just being mindful of some of the other sensory things is really important as well. I had worked with another patient who found sound and other people very activating for her. And just helping her to manage that and accept that, and to explore ways of managing it which is going to be helpful.” (Participant 5).
Techniques used to treat comorbid ASD/AN
“Basically would just ask her along the way, you know like questions checking in with her around, you know, the work we were doing and whether she thought she was getting stuck with ASD routines and habits, or it was more like her eating disorder that was in play. So kind of like trying to tailor it with her ASD in mind.” (Participant 2).
“And do lots of work around emotional identification and thought identification in session, and at a level that you might do even with young people or teenagers, or younger people and younger children, around that.” (Participant 5).
“I would be keeping it very simple, very basic and be doing a lot of work around mentalising as well in a way that I way if someone has got personality disorder or borderline personality disorder”. (Participant 9).
“What I do is that I ask them to write like, like write things before session and then to read it or ask me to read it so that it’s easier for them to write it down. I’ve done sessions where they actually don’t look at me. So the chair is turned, and they felt more comfortable talking to alternative objects- so they would bring something like I had a patient with a teddy bear, and she would talk to the teddy bear.”
“Lots of work around emotional identification and thought identification in session, and at a level that you might do even with young people or teenagers… around that. Like using faces with different emotional expressions on them and using that as a crib sheet that you have in session all the time, and asking them to point to what they’re feeling on there. I get them to colour in different colours to help them represent it.”