Autism and Eating Disorders

TLDR

Eating disorders often show up differently in autistic people than in neurotypicals. While

traditional anorexia is usually driven by body image concerns and fear of weight gain, autistic

individuals may restrict food due to sensory sensitivities, interoception differences, alexithymia,

or the effects of masking. Many don’t initially struggle with fat phobia at all, but starvation can

alter brain function and lead to fear of fatness over time. Treatment approaches may need to be

modified for autistic clients due to communication differences, sensory needs, and challenges

with emotional processing. A flexible, neurodiversity-affirming approach is key.

How Eating Disorders Present Differently in Autistic People: Understanding the Unique Connection

When we think of eating disorders like anorexia nervosa, we often imagine a person who is

intensely preoccupied with weight, body image, and the fear of becoming fat. This is a common

narrative for neurotypical individuals who suffer from eating disorders. However, for people with autism, the experience can look very different.

The Overlap Between Autism and Eating Disorders

There is a significant co-occurrence between autism and eating disorders (EDs). Research shows

that a higher proportion of both adolescents and adults with eating disorders score above

clinically significant thresholds on autism measures.

This suggests that many individuals with EDs may be undiagnosed autistic. This fact is often

realized after their disordered eating behaviors emerge or intensify. However, often these

individuals report noticing their autistic traits before their eating disorder symptoms began. It is

important for clinicians to explore the onset of these traits with their clients to avoid

misdiagnosis, misunderstanding, and inadequate treatment.

Body Image and Fat Phobia: Not Always Part of the Story

A major difference in how eating disorders can present in autistic people is the absence of body

image distress or fat phobia. Neurotypical individuals with anorexia report a deep fear of weight

gain and an overvaluation of thinness. However, autistic individuals often do not.

Instead, their restrictive eating patterns may be rooted in sensory sensitivities, routine adherence, or difficulty interpreting internal bodily signals, rather than a drive for thinness. This is why some clinicians and researchers now refer to this presentation as “atypical anorexia” in autism.

It’s important to note that while many autistic individuals do not start with a fear of fatness or

body dissatisfaction, long-term malnutrition and energy deficiency can change how the brain

functions. Starvation itself can induce obsessive thinking, increased anxiety, and the

development of new fears around weight gain, even in those who were previously neutral about

body image.

The Role of Interoception in Autistic Eating Disorders

A key area of interest is interoception, which is our brain’s ability to sense and interpret internal

cues like hunger, fullness, thirst, temperature, and heart rate. In autistic people, atypical

interoception is common and may significantly contribute to disordered eating.

• Some autistic individuals experience heightened interoceptive sensitivity, making sensations like fullness or hunger feel intense, distressing, or overwhelming. To avoid these discomforts, they may restrict food intake or suppress body signals over time.

• Others experience reduced interoceptive accuracy, meaning they may not accurately perceive hunger, thirst, or fullness cues. This can lead to irregular eating patterns or the use of food behaviors to regulate emotion or create structure.

  
  

In both cases, interoceptive differences can increase vulnerability to eating disorders, even in the

absence of body image concerns.

Alexithymia: When Feelings Are Hard to Name

Many autistic individuals also experience alexithymia, a trait characterized by difficulty

recognizing, identifying, and verbalizing one’s own emotions. This isn’t a refusal to engage in

emotional processing, nor a lack of desire; it’s simply a different way of experiencing and

navigating internal states.

In the context of eating disorder treatment, alexithymia can present a real challenge:

• Traditional therapy often involves naming feelings, tracking emotions, and connecting

  eating behaviors to emotional states. These tasks can feel inaccessible or even impossible

  for someone with alexithymia.

• Misunderstanding this emotional processing difference can lead to assumptions that the

  client is resistant because the “eating disorder is in charge”. In fact, the client may simply

  lack access to emotional clarity in the way neurotypical clients do.

This makes it essential to work with a clinician skilled in both autism and eating disorders -

someone who can adjust their therapeutic approach to honor neurodivergent communication and

emotional processing.

Masking and the Pressure to Conform

Another factor that contributes to the development of eating disorders in autistic individuals is

masking: the process of minimizing or hiding autistic traits to appear neurotypical. Masking

often involves rigid control, social mimicry, and self-suppression, all of which can be mentally

and physically exhausting.

For some autistic people, eating behaviors become a way to exert control, manage anxiety, or

cope with the stress of daily masking. Rigid routines around food, extreme pickiness, or

avoidance of eating in social situations may not stem from fat phobia but from a deeper need to

feel safe and regulated in a world that doesn’t feel made for them.

Differentiating Between Starvation Effects and Autistic Traits

One of the most important responsibilities a clinician has when working with an autistic person

with an eating disorder is the ability to differentiate between starvation-induced symptoms (such

as rigidity, obsessive thinking, and social withdrawal) and preexisting autistic traits.

What may look like resistance or inflexibility in treatment could, in fact, be a

neurodevelopmental trait. This is not something to be "fixed," but something to be understood

and supported.

Autistic traits are often adaptive survival mechanisms, not pathologies. A skilled clinician can

help discern what patterns need to be addressed for health and safety, and what behaviors may

simply be expressions of neurodivergent identity.

The Importance of Modifying Eating Disorder Treatment for Autistic Clients

Family-Based Treatment (FBT) is often considered the gold standard for adolescent eating

disorder recovery. However, some of the tenants of FBT may be challenging for autistic teens.

FBT relies on external control of eating, structured meal compliance, and emotional attunement

within the family system. These components may clash with the needs and communication styles

of autistic people. Therefore, it’s important to modify treatment to make sure it is neurodivergent

affirming.

Some key things to consider when developing treatment plans for clients with autism:

• Sensory needs around food (taste, texture, smell, temperature) may be misunderstood as

  resistance or defiance. It’s important not to assume these needs are “just the eating

  disorder talking.” There are some foods that a person’s sensory system may never be able

  to tolerate. Consider which food preferences were present prior to the onset of the eating

  disorder, introduce new foods gradually, and allow clients to give input regarding

  mealtimes.

• Consult with the client to see if there are things about the therapy space that cause

  sensory discomfort and make environmental modifications accordingly.

• Alexithymia may make emotional check-ins or shared emotional processing difficult or

  even inaccessible. Provide psychoeducation on emotional literacy as needed. Consider

  offering alternative outlets for emotional expression such as drawing, painting, writing, or

  playing music.

• Literal thinking and difficulty with cognitive flexibility can make some therapeutic

  strategies confusing or ineffective. It can be helpful to use a straight-forward, literal style

  of communication. Structure therapy sessions to be consistent and predictable and

  provide visual schedules.

• It is sometimes difficult to distinguish between autistic traits and ED-related behaviors,

  leading to unintentional invalidation or harm. Consider consulting with autism specialists,

  especially those with lived experience.

  
  

Final Thoughts

Eating disorders in autistic individuals are not just neurotypical EDs in disguise. They are often

driven by neurological differences, sensory processing patterns, alexithymia, and the emotional

toll of masking rather than a desire for thinness or a distorted body image.

By increasing awareness, challenging stereotypes, and advocating for neurodivergent-affirming

care, we can support autistic people on a path to recovery that honors their unique experiences.