Comprehensive Psychiatry 81 (2018) 66–72

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Comprehensive Psychiatry

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Subthreshold autism spectrum disorder in patients with eating disorders

L. Dell'Osso a, B. Carpita a,⁎, C. Gesi a, I.M. Cremone a, M. Corsi a, E. Massimetti a, D. Muti a,
E. Calderani b, G. Castellini b, M. Luciano c, V. Ricca b, C. Carmassi a, M. Maj c
a
Department of Clinical and Experimental Medicine, University of Pisa, Italy
b
Psychiatric Unit, Department of Neuropsychiatric Sciences, Florence University School of Medicine, 50134 Firenze, Italy
c
Department of Psychiatry, University of Naples SUN, Naples, Italy

a r t i c l e i n f o a b s t r a c t

Aim: Increasingly data suggest a possible overlap between psychopathological manifestations of eating disorders
(EDs) and autism spectrum disorders (ASD). The aim of the present study was to assess the presence of
subthreshold autism spectrum symptoms, by means of a recently validated instrument, in a sample of
participants with EDs, particularly comparing participants with or without binge eating behaviours.
Methods: 138 participants meeting DSM-5 criteria for EDs and 160 healthy control participants (HCs), were
recruited at 3 Italian University Departments of Psychiatry and assessed by the SCID-5, the Adult Autism
Subthreshold Spectrum (AdAS Spectrum) and the Eating Disorders Inventory, version 2 (EDI-2). ED participants
included: 46 with restrictive anorexia (AN-R); 24 with binge-purging type of Anorexia Nervosa (AN-BP); 34 with
Bulimia Nervosa (BN) and 34 with Binge Eating Disorder (BED). The sample was split in two groups: participants
with binge eating behaviours (BEB), in which were included participants with AN-BP, BN and BED, and
participants with restrictive behaviours (AN-R).
Results: participants with EDs showed significantly higher AdAS Spectrum total scores than HCs. Moreover, EDs
participants showed significantly higher scores on all AdAS Spectrum domains with the exception of Non verbal
communication and Hyper-Hypo reactivity to sensory input for AN-BP participants, and Childhood/Adolescence
domain for AN-BP and BED participants. Participants with AN-R scored significantly higher than participants
with BEB on the AdAS Spectrum total score, and on the Inflexibility and adherence to routine and Restricted
interest/rumination AdAS Spectrum domain scores. Significant correlations emerged between the Interpersonal
distrust EDI-2 sub-scale and the Non verbal communication and the Restricted interest and rumination AdAS
Spectrum domains; as well as between the Social insecurity EDI-2 sub-scale and the Inflexibility and adherence
to routine and Restricted interest and rumination domains in participants with EDs.
Conclusions: Our data corroborate the presence of higher subthreshold autism spectrum symptoms among
ED participants with respect to HCs, with particularly higher levels among restrictive participants. Relevant
correlations between subthreshold autism spectrum symptoms and EDI-2 Subscale also emerged.
© 2017 Elsevier Inc. All rights reserved.

1. Introduction healthy participants. However, most recent studies reported conflicting

Increasing attention has been recently devoted to detecting the
shared vulnerability between Anorexia Nervosa (AN) and Autism Spec-
trum Disorder (ASD) [1–3] upon the evidence of frequent AN comorbid-
ity in ASD [4–7], leading authors to highlight a possible conception of AN
as a neurodevelopmental disorder [8], besides propelling interest on the
possible overlap between Eating Disorders (EDs) and ASD [1,8,9].
In a large Swedish cohort of AN individuals (“the Göteborg AN
study”) [8,10–21], higher rates of ASD were reported with respect to
⁎ Corresponding author at: Department of Clinical and Experimental Medicine,
Section of Psychiatry, University of Pisa, Pisa, Italy.
E-mail address: barbara.carpita1986@gmail.com (B. Carpita).
results, despite instruments employed to assess symptoms often dif-
fered among studies leading to difficulties in comparing data. Pooni
et al. [22] using the Developmental, Dimensional and Diagnostic Inter-
view (3Di), found similar prevalence of ASD in healthy control partici-
pants and in participants with EDs, this latter showing only a higher
frequency of repetitive behaviours. Rhind reported a 4% rate of ASD
among AN participants by means of the Development and Well-being
Assessment (DAWBA) [23], while other studies reported higher rates
of ASD symptomatology in AN female participants by means of the Au-
tism Diagnostic Observation Schedule-Second Edition (ADOS-2), with a
prevalence range from 10% to 23% [24–27]. In particular, Mandy &
Tchanturia [28], testing the hypothesis that AN females with socio-
communicative deficit may have comorbid ASD, found that five out of
ten women with EDs had clinically suspected ASD.

https://doi.org/10.1016/j.comppsych.2017.11.007
0010-440X/© 2017 Elsevier Inc. All rights reserved.
 L. Dell'Osso et al. / Comprehensive Psychiatry 81 (2018) 66–72
On the other hand, several studies have reported that individuals
with ASD and AN seem to share common cognitive profiles defined by
rigidity, inflexibility, perfectionism, impaired social cognition and
executive functions [29–38], as well as social anhedonia [39,40]. AN
indivudals have also been shown to have increased attention to details,
poor results in advanced theory of mind and neurocognitive tests [20,
41], and a lack of ‘emotional intelligence’ [42,43]. These findings, togeth-
er with the spreading concept of “Broader Autism Phenotype” (that is to
say, subthreshold manifestations of ASD frequently found among unaf-
fected relatives of people with autistic conditions [44–49]), propelled a
growing body of studies aiming to investigate not only full-blown ASD
but also autistic traits among AN affected participants, most of which
used the Autism Spectrum Quotient (AQ) or its brief version (AQ-10)
as assessment tools [37,41,50–54]. A recent meta-analysis of these stud-
ies [3] showed that individuals with AN score significantly higher than
healthy controls on the AQ but they seldom exceed the cut-off score
for a full diagnosis of ASD. A possible interpretation of these results
could argue the fact that ED samples are mostly represented by females,
while available questionnaires for ASD have been criticized for being
tailored only on a male stereotype of ASD [55].
Despite evidences demonstrating the frequent diagnostic crossover
among different ED and despite recent trends in literature suggesting
to reconsider EDs from a trans-diagnostic perspective [56,57], a possible
relationship between autistic traits and EDs other than AN has been fair-
ly neglected in the literature [28,58]. Among the few studies, Vagni et al.
[59] recently examined a sample of ED participants, including AN, Bu-
limia Nervosa (BN) and Binge Eating Disorder (BED), using the Ritvo
Autism Asperger Diagnostic Scale Revised (RAADS-R) and reported
that 33% of ED participants scored above the cut-off without significant
differences between ED categories. The lack of studies is even more sur-
prising in light of the literature showing that the cognitive profile found
in both ASD and AN might be common to other EDs as well. For instance,
Medina-Pradas et al. [60] highlighted a poorer emotional theory of mind
in participants with BN or ED not otherwise specified compared to
healthy controls, while other studies reported alterations in cognitive
flexibility and social anhedonia not only in AN but also in BN partici-
pants [39,61]. Such evidence suggests that the relationship between au-
tistic traits and other EDs, such as BN and BED, may deserve further
investigation.
Considering ASD, it is also noteworthy that a growing number of
studies have highlighted remarkable gender differences in ASD clinical
presentation, focusing on female phenotype of ASD [62–66]. In this
regard, even without a diagnosis of ASD, higher autistic traits in AN
could still be in line with the conception of AN as a possible ASD pre-
sentation in females [2,67–70] as well as the presence of autistic traits
in childhood, which seems to increase the risk of developing EDs
[71–74]. However, ASD presence in AN populations may be over-
represented due to symptomatology arising not during early develop-
ment but in adolescence. Moreover, it is not clear if there is a peculiar re-
lationship between ASD and EDs, since ASD seems to be linked also with
other psychiatric disorders [25]. This over representation and the
marked gender-prevalence outline the need for accurate and careful as-
sessment of these pathological dimensions [75].
In the framework of a spectrum approach to psychopathology, pro-
posed by the Italian-American research project named Spectrum-project
(www.spectrumproject.org) [76–86], we recently developed and vali-
dated the Adult Autism Subthreshold Spectrum (AdAS Spectrum),
which aims to assess both typical and atypical symptoms, but also atten-
uated manifestations, personality traits, and behavioural features that
may be associated with ASD but which may also be present in
subthreshold or partial forms [55]. Compared to other available instru-
ments, the AdAS Spectrum, besides assessing more subtle manifesta-
tions of autism spectrum, investigates features that have been
suggested as the female phenotype of ASD [62–67]. More specifically,
gender-related manifestations included in the questionnaire refer either
to the tendency of women with ASD to camouflage by imitating others,
67
often adopting an alternative persona and acting as someone who is so-
cially successful, or to the proneness to avoid social interactions, choos-
ing instead to engage in creative solitary activities, read fiction, or spend
time with animals [67]. Moreover, since women with ASD are known to
cope with their own social incompetence by remaining peripheral in so-
cial situations also developing intense anxiety, some social anxiety-like
behavioural features have been included in the questionnaire [67,87].
Lastly, the AdAS Spectrum domain Restricted interest and rumination
took into account that fixated interests of ASD females are as strong as
in males but they likely focus on subjects that are common among
neurotypical counterparts as well [67]. Given the high prevalence of EDs
among females, we expect that the AdAS Spectrum might represent a
useful instrument to detect autistic traits underlying ED psycopathology.
The aim of the present study was to assess the presence of autism
spectrum disorder symptoms in a sample of participants diagnosed
with AN, BN and BED. Specifically, we aimed to test whether high
levels of autistic traits are present in AN participants even in the ab-
sence of full ASD diagnosis and whether they also characterize BN
and BED and/or they relate to specific cross-diagnostic eating behav-
iours (e.g., restrictive eating, binge-eating).
2. Methods
A sample of 138 participants with EDs, diagnosed in accordance to
DSM-5 criteria, and 160 Healthy Controls (HCs) without any current
or lifetime history of mental disorders were recruited at 3 Italian Uni-
versity Departments of Psychiatry (Pisa, Florence and Naples). We ex-
cluded participants who were aged below 18 years old, were unable
to complete the assessments due to language or intellectual impair-
ment, or with a diagnosis of Schizophrenia or full-blown ASD according
to the SCID-5. The HC group was recruited among participants attending
the Ophthalmology Clinic of the same University for a routine eye test,
as well as their friends or relatives, and assessed by means of the
SCID-5 to evaluate the presence of mental disorders. ED participants in-
cluded participants with AN (restrictive and binge-purging types: AN-R
and AN-BP), BN and BED. The sample was split in two groups: partici-
pants with binge eating behaviours (BEB) - including diagnosis of AN-
BP, BN, BED - and participants with restrictive behaviours (AN-R).
All participants received clear information about the study and had
the opportunity to ask questions before they provided a written
informed consent. The study was conducted in accordance with the
Declaration of Helsinki and the Ethics Committee of the Azienda
Ospedaliero-Universitaria of Pisa approved all recruitment and assess-
ment procedures.
2.1. Measures
The Structured Clinical Interview for DSM-5 [88] was used to assess
DSM-5 diagnosis by psychiatrists trained and certified in the use of this
instrument. Further, participants were asked to complete the AdAS
Spectrum and the the Eating Disorders Inventory, version 2 (EDI-2).
2.2. The Adult Autism Subthreshold Spectrum (AdAS Spectrum)
The AdAS Spectrum is a questionnaire developed by Dell'Osso et al.
[55], within the framework of the international research network called
Spectrum Project [47,48,76–80,89–91]. The instrument was devised to
assess the lifetime presence of the wide spectrum of manifestations as-
sociated with ASD, but which could be found even in individuals who do
not fulfill diagnostic criteria for a formal disorder: in this regard, it was
not developed to be a diagnostic instrument. On the contrary, it allows
evaluation of a broader area of clinical and non-clinical traits. It is com-
posed of 160 dichotomous questions (yes/no), grouped in seven
domains: (Childhood/adolescence, Verbal communication, Non-verbal
communication, Empathy, Inflexibility and adherence to routine, Restricted
interests and rumination, Hyper-hypo reactivity to sensory input). In the
68 L. Dell'Osso et al. / Comprehensive Psychiatry 81 (2018) 66–72
validation study [55], the ASD group showed significantly higher total
and domain scores compared to control group (67.71 ± 27.61 vs
33.15 ± 20.09 total score). The AdAS Spectrum demonstrated an excel-
lent reliability, with a Kuder-Richardson's coefficient of 0.964 for the
total score, and above 0.80 for each single domain, with the exception
of the Empathy and Hyper/hypo reactivity to sensory input domains,
which reported respectively a coefficient of 0.762 and 0.794. The test-
retest reliability was also demonstrated to be adequate (Intraclass Cor-
relation Coefficients above 0.90). Moreover, AdAS Spectrum total scores
were highly correlated with RAADS-14 and AQ total scores, with a
Pearson's r correlation coefficient respectively of 0.77 and 0.83, and
each AdAS Spectrum domain positively correlated with RAADS-14 and
AQ (ranging from r = 0.58 and r = 0.79).
2.3. The eating disorders inventory, version 2 (EDI-2)
The EDI-2 [92,93] is a widely used self-report instrument composed
of 91 items distributed in 11 sub-scales. This scale consists of the
original 64 items of EDI with the addition of 27 items organized in
three sub-scales (Ascetism, Impulsivity, Social insecurity). Response op-
tions are collected with a 6-points Liekert-scale. 3 sub-scales of the
questionnaire are designed to assess core symptoms of ED (Drive for
thinness, Bulimia, Body Dissatisfaction), while the other 8 sub-scales
provide an assessment of psychological traits typically associated with
EDs (Ineffectiveness, Maturity fears, Social insecurity, Perfectionism,
Interpersonal distrust, Impulsivity, Enteroceptive awareness, Ascetism).
3. Statistical analyses
Continuous variables were reported as mean ± standard deviation
(SD), whereas categorical variables were reported as percentages. Uni-
variate analysis of variance (ANOVA, with Tukey-B post hoc test for
the pairwise comparison between the groups) was adopted to compare
different ED sub-groups (AN-R, AN-BP, BN, BED) and HCs. Participants
were also compared by means of the independent sample t-test, accord-
ing to the presence/absence of BEB. The χ2 was used for comparisons of
categorical variables. Fisher test was used when appropriate. Pearson's
correlation was used to evaluate the associations between different var-
iables. Finally, on the basis of the significant correlation coefficients be-
tween AdAS Spectrum domain scores and EDI-2 sub-scales, multiple
linear regressions were conducted to identify the AdAS Spectrum do-
mains most strongly associated with each EDI-2 sub-scale. These latter
analyses were adjusted for age and BMI. All analyses were performed
using SPSS version 23 (SPSS Inc., Chicago, IL, USA) [94].
4. Results
4.1. Socio-demographic characteristics
All study groups reported more females than males with a statisti-
cally significant lower female/male ratio among healthy controls with
respect to all ED subgroups (See Table 1). Restrictive participants were
less likely to be engaged in a relationship and to be employed with re-
spect to participants with BEB. As expected, participants with AN
showed lower BMI with respect to the other diagnostic groups.
4.2. Clinical characteristics of the study sample
ED participants showed significantly higher AdAS Spectrum total
scores than HCs. Significantly higher scores also emerged in ED
participants on all AdAS Spectrum domains, with the exception of
the: Childhood/Adolescence domain in AN-BP and BED; Non verbal
communication and Hyper-Hypo reactivity to sensory input domains
for AN-BP (See Table 2). Furthermore, restrictive participants
showed significantly higher total AdAS Spectrum scores, as well as
Inflexibility and adherence to routine and Restricted interest/rumina-
tion AdAS Spectrum domain scores with respect to BEB participants.
Statistically significant correlations emerged between the AdAS
Spectrum total scores and Social insecurity and Interpersonal distrust
EDI-2 sub-scales. Moreover, the Verbal communication AdAS Spectrum
domain showed a correlation with the Ascetism EDI-2 sub-scale; the
AdAS Spectrum Non verbal communication, Inflexibility and adherence
to routine, Restricted interest and rumination, Hyper-Hypo reactivity to
sensory imput domains significantly correlated with the Social insecurity
EDI-2 sub-scales; while the Restricted interest and rumination and Inflex-
ibility and adherence to routine AdAS Spectrum domains correlated with
the Ineffectiveness EDI-2 sub-scale. The Non-verbal communication and
Inflexibility and adherence to routine AdAS Spectrum domains also signif-
icantly correlated with Interpersonal distrust EDI-2 sub-scale. Finally, the
Empathy AdAS Spectrum domain showed a statistically significant in-
verse correlation with Drive for thinness (See Table 3).
On the bases of multiple linear regressions, results showed that the
Inflexibility and adherence to routine AdAS Spectrum domain scores
were significantly associated with Ineffectiveness EDI-2 scores (R2 =
0.067, R2Adjusted = 0.041; β = 0.228, p = 0.018) despite failing after
adjusting for age and BMI. Several AdAS Spectrum domains were asso-
ciated with Social Insecurity EDI-2 scores: in particular Restricted Interest
and Rumination (R2 = 0.117, R2Adjusted = 0.093; β = 0.272, p = 0.004),
Nonverbal Communication (R2 = 0.084, R2Adjusted = 0.059; β = 0.202, p
= 0.036), Inflexibility and adherence to routine (R2 = 0.088, R2Adjusted =
0.063; β = 0.208, p = 0.028), Hyper-Hypo reactivity to sensory input (R2
= 0.112, R2Adjusted = 0.088; β =0.258, p = 0.005), and total AdAS Spec-
trum scores (R2 = 0.098, R2Adjusted = 0.074; β = 0.230, p = 0.013).
Restricted Interest and Rumination AdAS Spectrum domain scores were
significantly associated with Interpersonal Distrust EDI-2 scores (R2 =
0.064, R2Adjusted = 0.039; β = 0.242, p = 0.012), and Empathy AdAS
Spectrum domain scores was associated with Drive for Thinness EDI-2
scores (R2 = 0.133, R2Adjusted = 0.109; β = −0.245, p = 0.007). Finally,
Verbal Communication AdAS Spectrum domain scores was associated
with Ascetism EDI-2 scores (R2 = 0.082, R2Adjusted = 0.057; β = 0.186,
p = 0.044).
5. Discussion
To the best of our knowledge this study is the first to report adult au-
tism subthreshold spectrum symptoms in a sample of participants with
different EDs compared to a group of HCs. In particular, this is the first
study to explore the potential differences between ED participants
with BEB compared to restrictive ones. The results of the present
study corroborate previous data on high autism spectrum symptom
levels among ED participants [24–28,58] with respect to HC partici-
pants, besides first highlighting significantly higher AdAS Spectrum
total scores in AN-R participants without a DSM-5 diagnosis of ASD
compared to HC and to ED participants with BEB. These data corrobo-
rate the presence of higher rates of not only clinically significant ASD
among restrictive participants, as reported among AN ones [8,24–27],
but also of subthreshold autism spectrum symptoms [3]. This latter con-
dition is often being undetected or misdiagnosed in this kind of individ-
uals [37,41,50–53,55]. Increasing literature has most recently evaluated
the relationships between EDs and ASD. However, most of these studies
have focused on AN, with almost no data about the differences between
BEB and restrictive individuals [28,58]. To the best of our knowledge, we
first reported significantly higher subthreshold autism spectrum symp-
toms, detected by using the AdAS Spectrum, in restrictive ED partici-
pants compared to ED participants with BEB, as well as between these
latter and HCs. A possible interpretation of these results may suggest
the presence of a continuum across increasing degrees of severity of
the subthreshold autism spectrum among these diagnostic groups.
By means of the AdAS Spectrum domains we could also shed more
light on specific features of the subthreshold autism spectrum symp-
tomatology among ED participants with restrictive or binge eating
 L. Dell'Osso et al. / Comprehensive Psychiatry 81 (2018) 66–72 69

Table 1
Sample characteristics.

HC (n:160) AN-R (n:46) AN-BP (n:24) BN (n:34) BED (n:34) χ2 BEB χ2

N(%) N(%) N(%) N(%) N(%) N(%) vs AN-R

Sex
Female 97(60.6) 45(97.8) 24(100.0) 33(97.1) 28(82.4) 49.59⁎† 85(92.4) 0.81
Male 63(39.4) 1(2.2) 0(0.0) 1(2.9) 6(17.6) 7(7.6)
In a relationship
Yes 15(9.5) 5(10.9) 6(25.0) 10(29.4) 15(44.1) 29.73⁎†† 31(33.7) 7.15⁎⁎
No 143(90.5) 41(89.1) 18(75.0) 24(70.6) 19(55.9) 61(66.3)
Occupation
Employed 39(25.2) 11(23.9) 8(33.3) 19(55.9) 16(47.1) 39.42⁎††† 43(46.7) 5.78⁎⁎
Unemployed 116(74.8) 35(76.1) 16(66.7) 15(44.1) 18 (52.9) 49(53.3)
Speech learning disability
Yes 5(3.2) 3(6.5) 1(4.2) 2(5.9) 1(2.9) 1.42 4(4.3) 0.02
No 152(96.8) 43(93.5) 23(95.8) 32(94.1) 33(97.1) 88(97.5)
Motor developmental disability
Yes 4(2.5) 0(0.0) 1(4.2) 2(5.9) 0(0.0) 4.11 3(3.3) 0.38
No 153(97.5) 46(100.0) 23(95.8) 32(94.1) 34(100.0) 89(96.7)
Lifetime comobrbidity§
Bipolar II – 3(7.0) 0(0.0) 0(0.0) 0(0.0) – 0(0.0) 6.13⁎⁎
Major depression – 5(11.6) 4(17.4) 2(5.9) 8(23.5) 1.61 14(15.4) 0.19
Panic disorder – 4(9.3) 2(8.7) 1(2.9) 2(5.9) 0.67 5(5.5) 0.54
Agoraphobia – 1(2.3) 0(0.0) 0(0.0) 0(0.0) – 0(0.0) 2.01
Social anxiety – 1(2.3) 1(4.3) 0(0.0) 0(0.0) – 1(1.1) 0.25
GAD – 1(2.3) 0(0.0) 0(0.0) 2(5.9) – 2(2.2) 0.00
OCD – 0(0.0) 2(8.7) 0(0.0) 0(0.0) 3.42⁎⁎ 2(2.2) 1.02

HC AN-R AN-BP BN BED F BEB t

Mean ± SD Mean ± SD Mean ± SD Mean ± SD Mean ± SD Mean ± SD vs AN-R

Age 26.5 ± 9.1 29.3 ± 11.0 27.8 ± 6.8 32.1 ± 10.1 40.5 ± 16.7 13.46#⁎ 33.9 ± 13.2 −2.18⁎⁎
BMI 16.8 ± 2.4 16.6 ± 1.6 22.9 ± 4.7 38.6 ± 7.3 184.64##⁎ 26.9 ± 10.5 −9.09⁎
Education (years) 14.9 ± 2.6 13.7 ± 3.8 14.7 ± 3.8 13.7 ± 3.0 12.0 ± 3.6 7.18###⁎ 13.3 ± 13.3 0.51

Statistics: ANOVA for between groups comparisons. Independent sample t-test for comparisons between binge eating and restrictive patients. Chi square or Fisher's test for categorical
variables.
BEB = Binge Eating Behaviours, being AN-BP, BN and BED together.
⁎ p b 0.001.
⁎⁎ p b 0.05.
†
♀: HC b all; BED N AN-R, AN-BP.
††
In a relationship: BED, BN N HC, AN-R.
†††
Employed: BN N HC, AN-R; BED N HC.
#
BED N HC, AN-R, AN-BP, BN.
##
BED N BN N AN-R, AN-BP.
###
AN-R, HC N BED.
§
0 patients endorsed criteria for Bipolar I disorder and Schizophrenia.

behaviours and HC participants. Our results confirmed significantly
higher scores in specific AdAS Spectrum domains, such as the Inflexibil-
ity and adherence to routine and Restricted interest/rumination, with
higher scores in restrictive ED participants than in BEB ones, although
BEB participants scored higher than HCs. Rigid and stereotyped eating
habits, incessant ruminations about body weight, inflexibility in food
selection are cognitive and behavioural symptoms well know as typical
features of restrictive AN participants [29–34], and authors have recently
debated how rigidity and inflexibility and repetitive behaviours in AN
eating patterns may resemble restricted interests of ASD [31,37,39,40,
42,43,95,96]. Inhibition and impairment in social cognition have been
recently suggested as comorbid ASD traits besides rigidity, inflexibility
or perfectionism in AN [26,29–34].
When correlating the AdAS Spectrum scores with the symptoms
assessed by the EDI-2 in ED participants, we highlighted significant
correlations between the AdAS Spectrum total scores and the Social
insecurity and Interpersonal distrust EDI-2 sub-scales; the same EDI-2
sub-scales in which AN-R participants scored higher than participants
with BEB. Moreover, significant correlations emerged between the
Non verbal communication and Restricted interest and rumination AdAS
Spectrum domains and the same EDI-2 sub-scales, suggesting a possible
relationship of these two dimensions of subthreshold autism spectrum
symptomatology and interpersonal related symptoms of EDs. Further,
also the Inflexibility and adherence to routine AdAS Spectrum domain
showed a correlation with the Social insecurity EDI-2 sub-scale, corrob-
orating previous data highlighting difficulties in social interactions and
poor social skills in individuals with EDs, and in particular with AN
[20,26,30,34]. A possible interpretation of these results could suggest a
link between social impairment and subthreshold autism spectrum in
individuals with EDs. However, it's important to note that the possibility
of interpersonal communication deficits to be a consequence, and not a
pre-existing and predisposing factor, of EDs cannot be excluded, and
further studies are needed. This is a cross-sectional study, therefore it
is not possible to assess if EDs are preceded or followed by autistic traits.
As other authors stated, autistic traits could actually be a result of mal-
nutrition and starvation in AN participants, and they could be better
considered as a maintaining factor for the altered eating behaviour
[22,37]. From the opposing point of view, it is important to highlight
that most of the previous studies have focused only on AN, while in
our sample there are participants with AN, BN and BED: considering
that BEB participants scored higher than HCs (although they scored
lower than AN-R participants) on AdAS Spectrum, it seems that autistic
traits could not be an effect of starvation, because BEB participants are
affected by kinds of EDs in which starvation is not involved. However,
as other authors stated, it is important to note that ASD is a condition
that seems to be increased also in other psychiatric disorders: further
cross-diagnostic studies are needed to clarify if there is a peculiar rela-
tionship between EDs and ASD, or if the presence of ASD is related to
psychopathology in general [25,75].
When discussing the results of the present study we should also take
into account some major limitations. As just stated above, the main one
is about the cross-sectional design of the study that did not allow us to
70 L. Dell'Osso et al. / Comprehensive Psychiatry 81 (2018) 66–72

Table 2
ADAS and EDI-2 domain scores.

HC (n:160) AN-R (n:46) AN-BP (n:24) BN (n:34) BED (n:34) F BEB HC vs AN-R vs BEB
Mean ± SD F

ADAS
Childhood/adolescence 21.4 ± 15.3 38.6 ± 21.5# 31.2 ± 15.8 34.6 ± 21.8# 31.2 ± 19.7 10.67⁎ 32.5 ± 19.5 21.23⁎§
Verbal communication 18.6 ± 14.2 37.4 ± 18.6# 25.8 ± 16.1 32.1 ± 17.0# 34.0 ± 18.2# 13.54⁎ 31.1 ± 17.4 25.31⁎§
Nonverbal communication 24.7 ± 16.8 42.6 ± 16.2# 37.9 ± 15.2# 39.3 ± 16.5# 37.4 ± 14.7# 16.29⁎ 38.2 ± 15.4 32.65⁎§
Empathy 23.5 ± 19.5 32.5 ± 19.2# 33.4 ± 0.19.9# 30.4 ± 17.9# 33.2 ± 18.0# 11.36⁎ 32.2 ± 18.3 21.64⁎§
Inflexibility and adherence to routine 21.7 ± 13.8 41.8 ± 19.8# 36.6 ± 13.0# 33.2 ± 16.5# 31.2 ± 13.6# 19.79⁎& 33.3 ± 14.6 38.70⁎§§
Restricted interest and rumination 23.8 ± 18.3 44.5 ± 25.1# 39.9 ± 14.3# 34.6 ± 19.5# 34.0 ± 17.0# 13.16⁎ 35.8 ± 17.3 25.60⁎§§
Hyper-hypo reactivity to sensory input 12.8 ± 13.2 27.9 ± 22.7# 18.1 ± 15.4 26.1 ± 0.18.0# 28.5 ± 18.3# 13.67⁎ 24.9 ± 17.8 24.01⁎§
Total score 33.2 ± 20.1 62.3 ± 26.7# 52.5 ± 17.4# 52.8 ± 24.7# 52.1 ± 20.5# 21.77⁎ 52.4 ± 0.21.2 43.82⁎§§
EDI AN-R vs BEB
t
Ineffectiveness 15.4 ± 7.2 14.7 ± 7.9 12.8 ± 7.4 12.6 ± 5.9 1.27 13.3 ± 7.0 1.56
Maturity fears 8.7 ± 6.6 8.1 ± 6.1 9.4 ± 5.7 11.0 ± 4.5 1.44 9.7 ± 5.4 −0.78
Social insecurity 11.3 ± 4.2 11.1 ± 4.4 9.0 ± 3.5 8.0 ± 5.3 4.22⁎⁎† 9.2 ± 4.6 2.42⁎⁎
Body dissatisfaction 16.3 ± 7.1 16.4 ± 8.1 16.4 ± 8.5 20.9 ± 4.6 3.28⁎⁎†† 18.2 ± 7.3 −1.34
Perfectionism 6.5 ± 4.3 5.2 ± 4.8 6.9 ± 5.5 8.0 ± 3.7 1.73 6.8 ± 4.7 −0.43
Interpersonal distrust 10.4 ± 4.0 8.4 ± 3.9 7.8 ± 4.5 8.0 ± 5.2 2.63 8.1 ± 4.6 2.79⁎⁎
Impulsivity 8.3 ± 6.8 7.8 ± 5.0 7.9 ± 6.9 6.4 ± 7.6 0.54 7.3 ± 6.7 0.82
Drive for thinness 13.9 ± 5.8 11.8 ± 7.4 14.8 ± 6.5 16.0 ± 4.7 2.28††† 14.4 ± 6.3 −0.44
Bulimia 4.1 ± 4.9 6.8 ± 6.1 7.0 ± 7.2 5.4 ± 5.6 1.68 6.3 ± 6.2 −2.12⁎⁎
Enteroceptive awareness 14.0 ± 6.9 10.3 ± 5.3 13.8 ± 7.7 12.2 ± 3.6 2.14 12.2 ± 5.7 1.52
Ascetism 9.1 ± 4.7 7.0 ± 3.7 8.9 ± 6.4 10.3 ± 4.7 2.41††† 8.9 ± 4.7 0.12

Statistics: ANOVA for between groups comparisons (Games-Howell or Bonferroni for post-hoc as appropriate). Independent sample t-test for comparisons between binge eating and
restrictive patients. Chi square for categorical variables.
BEB = Binge Eating Behaviours, being AN-BP, BN and BED together.
#
p b 0.05 vs HC;
⁎ p b 0.001.
⁎⁎ p b 0.05.
&
AN-R N BED.
†
AN-R, AN-BP N BED.
††
BED N HC.
†††
BED N AN-BP.
§
AN-R, BEB N HC.
§§
AN-R N BEB N HC.

evaluate the temporal relationship between autistic symptoms and EDs
and, subsequently, if autistic spectrum should be considered as a risk
factor or a consequence of EDs. The second limitation is the limited sam-
ple size that may prevent from highlighting further significances. This
also may have impacted on the possibility to have a matched control
group. Further studies are thus warranted in larger samples with controls
matched for sex, age and education. Consistently, the logistic regression
was adjusted only for age and BMI, which seem to be the possible major
confounding factors in this study: further studies in larger samples may
account for the impact of gender and education. Finally, both AdAS
Spectrum and EDI-2 are self-report instruments and they could be less
accurate in assessing ASD and EDs symptoms, because they are exposed
to overstatement or minimization depending on participant judgment.
In particular, in the Childhood/Adolescence domain of the AdAS Spectrum,
participants could not correctly recall the actual presence of symptoms.
There is also the possibility that, due to the self-report employing
of the instrument, symptoms of ASD could not have been correctly
distinguished from symptoms of other disorders with overlapping
manifestations (such as Schizophrenia or Social Anxiety Disorder).
6. Conclusions
Despite the described limitations, our study show that there are
higher levels of autistic subthreshold symptoms among participants

Table 3
Pearson's correlation between ADAS and EDI-2 scores in patients group.

ADAS CHAD VC NVC EMP ROUT REST REACT TOTAL

EDI
Ineffectiveness 0.059 0.086 0.071 −0.130 0.245## 0.197# 0.161 0.173
Maturity fears −0.001 0.056 0.035 0.033 −0.065 0.063 −0.040 0.006
Social insecurity 0.145 0.166 0.228# −0.139 0.245## 0.305## 0.225# 0.256##
Body dissatisfaction −0.040 0.010 −0.109 −0.055 −0.109 −0.111 0.043 −0.088
Perfectionism −0.008 −0.065 −0.108 −0.151 −0.147 −0.114 −0.095 −0.119
Interpersonal distrust 0.183 0.160 0.212# −0.139 0.180 0.246## 0.161 0.218#
Impulsivity −0.068 −0.043 −0.112 0.125 0.052 0.055 0.050 0.015
Drive for thinness 0.034 0.021 −0.086 −0.223# −0.050 −0.097 0.049 −0.062
Bulimia −0.043 −0.049 −0.119 0.067 0.038 −0.048 0.117 −0.018
Enteroceptive awareness −0.100 0.009 −0.047 −0.002 0.032 0.059 0.081 0.033
Ascetism 0.037 0.188# −0.060 0.026 0.033 0.121 0.147 0.100

Abbreviations: CHAD = Childhood/Adolescence; VC = Verbal Communication; NVC = Nonverbal Communication; EMP = Empathy; ROUT = Inflexibility and adherence to routine;
REST = Restricted interest and rumination; REACT = Hyper-Hypo reactivity to sensory input.
Statistics: Pearsons's correlation.
We have marked in bold the statistically significant data.
#
p b 0.05.
##
p b 0.01.
 L. Dell'Osso et al. / Comprehensive Psychiatry 81 (2018) 66–72
with AN, BN and BED compared to general population. We found that
restrictive participants are affected by higher social insecurity and inter-
personal distrust, as recorded using EDI-2, and higher autistic traits than
participants with BEB: in particular higher inflexibility, adherence to
routine and restricted interest/rumination, as demonstrated by the
higher scores in these AdAS Spectrum domains. These findings could
have significant implications for both clinical and research perspectives,
helping to identify individuals at risk for EDs and shedding more light
on psychopathology and different clinical presentations of ASD. Further
studies in wider samples, and in particular of longitudinal design, are
needed to clarify the relationship among EDs and subthreshold as well
as overthreshold ASD.
Acknowledgment
The study was supported by the European Project TRIGGER
(Transforming Institutions by Gendering Contents and Gaining Quality
in Research – Grant agreement no. 611034).
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