Understanding Eating Behaviours in Autistic Women with Eating Disorders

This thesis addresses gaps in the understanding of eating disorders (EDs) in autistic women by systematically examining how their eating behaviors compare to those of non-autistic women with EDs, autistic women without EDs, and non-autistic controls. The primary focus is on a broad range of eating behaviors, including traditionally disordered eating behaviors, autism-related eating behaviors, ARFID symptomatology, and picky eating. In addition, psychological distress and mental health–related quality of life are explored to further assess the clinical complexity of this group. Cognitive flexibility, a neurocognitive trait known to differ in both autism and ED populations, is examined as a potential mechanism shaping these patterns. The overarching aim is to generate a more nuanced understanding of ED presentations in autistic women that reflects the interplay between autism characteristics and ED symptomatology and can inform more appropriate forms of care. Each chapter contributes to this integrated understanding. Chapter 2 demonstrates that although problematic eating behaviors in autistic women are increasingly acknowledged, the empirical literature remains limited and fragmented, often excluding autistic adults or overlooking gender-specific presentations. Chapter 3 explores the intersection of autism and EDs and argues that traditional ED models often fail to account for the lived experiences of autistic women, with implications for assessment, diagnosis, and treatment adaptation. Chapter 4 provides empirical evidence that autistic women with EDs report both traditionally disordered and autism-related eating behaviors, alongside elevated ARFID symptomatology, higher psychological distress, and lower mental health–related quality of life. Chapter 5 examines cognitive flexibility and finds it to be more strongly linked to eating difficulties in autistic than in non-autistic women. A central finding is that autistic women with EDs present with a dual pattern of eating behaviors. They exhibit high levels of autism-related eating behaviors, such as sensory-based food avoidance, food selectivity, and meal-related rigidity, alongside traditionally disordered eating behaviors, including dietary restraint, fear of weight gain, bingeing, and purging. Autistic women with EDs score higher than all other groups (including non-autistic women with EDs) on measures of disordered eating, autism-related eating behaviors, ARFID symptomatology, and picky eating. This pattern indicates a high level of clinical need that may not be adequately addressed by standard ED frameworks, which may misinterpret autism-related eating behaviors as inherently disordered and overlook autism-specific cognitive and sensory features. Cognitive flexibility appears to play a meaningful role in this complexity. Autistic women, regardless of ED status, report greater impairments in cognitive flexibility than non-autistic women. Within autistic individuals, attention to detail is associated with ED pathology and ARFID symptoms, suggesting that autism-related cognitive traits may contribute to the maintenance of rigid eating patterns and require careful differentiation in clinical formulation. Finally, the findings highlight a substantial psychological burden in autistic women with EDs, including elevated distress, broad comorbidity, and reduced mental health–related quality of life. Together, these results indicate that current diagnostic and treatment models may not fully capture the complexity of ED presentations in autistic women, underscoring the need for careful diagnostic assessment and personalized, autism-informed care.