A Qualitative Study of Friendship in Patients with Anorexia Nervosa and Possible Autism Spectrum Disorder


Difficulties in friendships have been reported both in people with Autism Spectrum Disorder (ASD) and in individuals with Anorexia Nervosa (AN). This small-scale qualitative study aimed to evaluate the friendship experiences of seven patients with AN who presented with possible ASD traits; to determine whether their experiences were reflective of those found in people with ASD, and whether any difficulties were present before the onset of their eating disorder. Participants were interviewed using the ADOS-G and the interviews were transcribed and analysed. Four principle themes emerged from the thematic analysis: limited social network, lack of contact or communication, difficulty understanding the concept of friendship, and focus of attention away from the self; which could not be explained by the state of starvation alone. The evidence presented here not only reflects the friendship experiences of individuals with AN as documented in the literature, but also the friendship difficulties which have been observed in people with ASD without a comorbid eating disorder. The findings provide evidence that friendship difficulties experienced by people with AN precede the onset of the eating disorder and therefore offer support for the idea of a shared phenotype between AN and ASD. This study also highlights the need to address friendship difficulties in treatment interventions for AN in order to promote recovery. Further research is warranted to better explore the friendship similarities between people with AN and ASD, and to develop friendship focused interventions for patients with AN.

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Doris, E. , Westwood, H. , Mandy, W. & Tchanturia, K. (2014). A Qualitative Study of Friendship in Patients with Anorexia Nervosa and Possible Autism Spectrum Disorder. Psychology, 5, 1338-1349. doi: 10.4236/psych.2014.511144.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Allison, C., Auyeung, B., & Baron-Cohen, S. (2012). Toward Brief “Red Flags” for Autism Screening: The Short Autism Spectrum Quotient and the Short Quantitative Checklist in 1000 Cases and 3000 Controls. Journal of the American Academy of Child and Adolescent Psychiatry, 51, 202-212.
[2] American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
[3] Baron-Cohen, S., Leslie, A. M., & Frith, U. (1985). Does the Autistic Child Have a “Theory of Mind”? Cognition, 21, 37-46.
[4] Baron-Cohen, S., & Wheelwright, S. (2003). The Friendship Questionnaire: An Investigation of Adults with Asperger Syndrome or High-Functioning Autism, and Normal Sex Differences. Journal of Autism and Developmental Disorders, 33, 509-517.
[5] Bauminger, N., & Kasari, C. (2000). Loneliness and Friendship in high-Functioning Children with Autism. Child Development, 71, 447-456.
[6] Bauminger, N., & Shulman, C. (2003). The Development and Maintenance of Friendship in High-Functioning Children with Autism: Maternal Perception. Autism, 7, 81-97.
[7] Bauminger, N., Solomon, M., Aviezer, A., Heung, K., Gazit, L., Brown, J., & Rogers, S. J. (2008). Children with Autism and Their Friends: A Multidimensional Study of Friendship in High-Functioning Autism Spectrum Disorder. Journal of Abnormal Child Psychology, 36, 135-150.
[8] Booth, A. (1972). Sex and Social Participation. American Sociological Review, 37, 183-193.
[9] Braun, V., & Clarke, V. (2006). Using Thematic Analysis in Psychology. Qualitative Research in Psychology, 3, 77-101.
[10] Carrington, S., Templeton, E., & Papinczak, T. (2003). Adolescents with Asperger Syndrome and Perceptions of Friendship. Focus on Autism and other Developmental Disabilities, 18, 211-218.
[11] Davies, H., Schmidt, U., Stahl, D., & Tchanturia, K. (2011). Evoked Facial Emotional Expression and Emotional Experience in People with Anorexia Nervosa. International Journal of Eating Disorders, 44, 531-539.
[12] Davies, H., Schmidt, U., & Tchanturia, K. (2013). Emotional Facial Expression in Women Recovered from Anorexia Nervosa. BMC Psychiatry, 13, 291.
[13] Davies, S. (2004). A Group-Work Approach to Addressing Friendship Issues in the Treatment of Adolescents with Eating Disorders. Clinical Child Psychology and Psychiatry, 9, 519-531.
[14] Fairburn, C. G., Cooper, Z., Doll, H. A., & Welch, S. L. (1999). Risk Factors for Anorexia Nervosa: Three Integrated Case-Control Comparisons. JAMA Psychiatry, 56, 468-476.
[15] Fleming, C., Doris, E., & Tchanturia, K. (2014). Self-Esteem Group Work for Inpatients with Anorexia Nervosa. Advances in Eating Disorders: Theory, Research and Practice.
[16] Flora, C. (2013). Friendfluence: The Surprising Ways Friends Make Us Who We Are. New York: Random House Inc., Doubleday.
[17] Frith, U. (1989). Autism: Explaining the Enigma. Oxford: Blackwell Publishing.
[18] Geller, J., Zaitsoff, S. L., & Srikameswaran, S. (2002). Beyond Shape and Weight: Exploring the Relationship between Non-Body Determinants of Self-Esteem and Eating Disorder Symptoms in Adolescent Females. International Journal of Eating Disorders, 32, 344-351.
[19] Gillberg, C. (1985). Autism and Anorexia Nervosa: Related Conditions? Nordic Journal of Psychiatry, 39, 307-312.
[20] Gillberg, C., & Rastam, M. (1992). Do Some Cases of Anorexia Nervosa Reflect Underlying Autistic-Like Conditions? Behavioural Neurology, 5, 27-32.
[21] Hambrook, D., Brown, G., & Tchanturia, K. (2012). Emotional Intelligence in Anorexia Nervosa: Is Anxiety a Missing Piece of the Puzzle? Psychiatry Research, 200, 12-19.
[22] Hambook, D., Tchanturia, K., Schmidt, U., Russell, T., & Treasure, J. (2008). Empathy, Systemizing, and Autistic Traits in Anorexia Nervosa: A Pilot Study. British Journal of Clinical Psychology, 47, 335-339.
[23] Harrison, A., Mountford, V., & Tchanturia, K. (2014). Social Anhedonia and Work and Social Functioning in the Acute and Recovered Phases of Eating Disorders. Psychiatry Research, 218, 187-194.
[24] Harrison, A., Sullivan, S., Tchanturia, K., & Treasure, J. (2010). Emotional Functioning in Eating Disorders: Attentional Bias, Emotion Recognition and Emotion Regulation. Psychological Medicine, 40, 1887-1897.
[25] Harney, M. B., Fitzsimmons-Craft, E. E., Maldonado, C. R., & Bardone-Cone, A. M. (2014). Negative Affective Experiences in Relation to Stages of Eating Disorder Recovery. Eating Behaviors, 15, 24-30.
[26] Huke, V., Turk, J., Saeidi, S., Kent, A., & Morgan, J. F. (2013). Autism Spectrum Disorders in Eating Disorder Populations: A Systematic Review. European Eating Disorders Review, 21, 345-351.
[27] Huon, G., & Brown, L. B. (1984). Psychological Correlates of Weight Control among Anorexia Nervosa Patients and Normal Girls. British Journal of Medical Psychology, 57, 61-66.
[28] Krug, I., Penelo, E., Fernandez-Aranda, F., Anderluh, M., Bellodi, L., Cellini, E., Bernardo, M., Granero, R., Karwautz, A., Nacmias, B., Ricca, V., Sorbi, S., Tchanturia, K., Wagner, G., Collier, D., & Treasure, J. (2012). Low Social Interactions in Eating Disorder Patients in Childhood and Adulthood: A Multi-Centre European Case Control Study. Journal of Health Psychology, 18, 26-37.
[29] Kuo, M. H., Orsmond, G. I., Cohn, E. S., & Coster, W. J. (2011). Friendship Characteristics and Activity Patterns of Adolescents with an Autism Spectrum Disorder. Autism, 17, 481-500.
[30] Jackson, T., Weiss, K. E., Lunquist, J. J., & Soderlind, A. (2005). Sociotrophy and Perceptions of Interpersonal Relationships as Predictors of Eating Disturbances among College Women: Two Prospective Studies. The Journal of Genetic Psychology: Research and Theory on Human Development, 166, 346-360.
[31] Jones, L., Harmer, C., Cowen, P., & Cooper, M. (2008). Emotional Face Processing in Women with High and Low Levels of Eating Disorder Related Symptoms. Eating Behaviors, 9, 389-397.
[32] Lang, K., Lopez, C., Stahl, D., Tchanturia, K., & Treasure, J. (2014). Central Coherence in Eating Disorders: An Updated Systematic Review and Meta-Analysis. World Journal of Biological Psychiatry, 1, 1-13.
[33] Larson, R., & Verma, S. (1999). How Children and Adolescents Spend Time across the World: Work, Play and Developmental Opportunities. Psychological Bulletin, 125, 701-736.
[34] Lombardo, M. V., Barnes, J. L., Wheelwright, S. J., & Baron-Cohen, S. (2007). Self-Referential Cognition and Empathy in Autism. PloS ONE, 9, Article ID: e883.
[35] Lord, C., Risi, S., Lambrecht, L., Cook, E. H., Leventhal, B. L., DiLavore, P. C., Pickles, A., & Rutter, M. (2000). The Autism Diagnostic Observation Schedule—Generic: A Standard Measure of Social and Communication Deficits Associated with the Spectrum of Autism. Journal of Autism and Developmental Disorders, 30, 205-223.
[36] Maccoby, E. E., & Jacklin, C. N. (1974). The Psychology of Sex Differences. Stanford, CA: Stanford University Press.
[37] Mazurek, M. O. (2013). Loneliness, Friendship and Well-Being in Adults with Autism Spectrum Disorders. Autism, 1-10.
[38] Morris, R., Bramham, J., Smith, E., & Tchanturia, K. (2014). Empathy and Social Functioning in Anorexia Nervosa before and after Recovery. Cognitive Neuropsychiatry, 19, 47-57.
[39] Nowakowski, M. E., McFarlane, T., & Cassin, S. (2013). Alexithymia and Eating Disorders: A Critical Review of the Literature. Journal of Eating Disorders, 1, 21.
[40] Oldershaw, A., Hambrook, D., Tchanturia, K., Treasure, J., & Schmidt, U. (2010). Emotional Theory of Mind and Emotional Awareness in Recovered Anorexia Nervosa Patients. Psychosomatic Medicine, 72, 73-79.
[41] Oldershaw, A., Treasure, J., Hambrook, D., Tchanturia, K., & Schmidt, U. (2011). Is Anorexia Nervosa a Version of Autism Spectrum Disorders? European Eating Disorders Review, 19, 462-474.
[42] Orsmond, G. I., Krauss, M. W., & Seltzer, M. M. (2004). Peer Relationships and Social and Recreational Activities among Adolescents and Adults with Autism. Journal of Autism and Developmental Disorders, 34, 245-256.
[43] Pritchard, M. E., & Yalch, K. L. (2009). Relationships among Loneliness, Interpersonal Dependency and Disordered Eating in Young Adults. Personality and Individual Differences, 46, 341-346.
[44] Rotheram-Fuller, E., Kasari, C., Chamberlain, B., & Locke, J. (2010). Social Involvement of Children with Autism Spectrum Disorders in Elementary School Classrooms. Journal of Child Psychology and Psychiatry, 51, 1227-1234.
[45] Russell, T. A., Schmidt, U., Doherty, L., Young, V., & Tchanturia, K. (2009). Aspects of Social Cognition in Anorexia Nervosa: Affective and Cognitive Theory of Mind. Psychiatry Research, 168, 181-185.
[46] Silvera, D. H., Bergensen, T. D., Bjorgum, L., Perry, J. A., Rosenvinge, J. H., & Holte, A. (1998). Analysing the Relation between Self-Esteem and Eating Disorders: Differential Effects of Self-Liking and Self-Competence. Eating and Weight Disorders, 3, 95-99.
[47] Silverstone, P. H. (1992). Is Chronic Low Self-Esteem the Cause of Eating Disorders? Medical Hypotheses, 39, 311-315.
[48] Tani, P., Lindberg, N., Joukamaa, M., Nieminen-von Wendt, T., von Wendt, L., Appelberg, B. et al. (2004). Asperger Syndrome, Alexithymia and Perception of Sleep. Neuropsychobiology, 49, 64-70.
[49] Tchanturia, K., Davies, H., Harrison, A., Fox, J., Treasure, J., & Schmidt, U. (2012). Altered Social Hedonic Processing in Eating Disorders. International Journal of Eating Disorders, 45, 962-969.
[50] Tchanturia, K., Davies, H., Harrison, A., Roberts, M., Nakazato, M., Schmidt, U., Treasure, J., & Morris, R. (2012). Poor Cognitive Flexibility in Eating Disorders: Examining the Evidence Using the Wisconcin Cart Sorting Task. PLoS ONE, 7, Article ID: e28331.
[51] Tchanturia, K., Hambrook, D., Curtis, H., Jones, T., Lounes, N., Fenn, K., Keys, A., Stivenson, L., & Davies, H. (2013). Work and Social Adjustment in Patients with Anorexia Nervosa. Comprehensive Psychiatry, 54, 41-45.
[52] Tchanturia, K., Happe, F., Godley, J., Treasure, J., Bara-Carril, N., & Schmidt, U. (2004). “Theory of Mind” in Anorexia Nervosa. European Eating Disorders Review, 12, 361-366.
[53] Tchanturia, K., Lloyd, S., & Lang, K. (2013). Cognitive Remediation Therapy for Anorexia Nervosa: Current Evidence and Future Research Directions. International Journal of Eating Disorders, 46, 492-495.
[54] Tchanturia, K., Smith, E., Weineck, F., Fidanboylu, E., Kern, N., Treasure, J., & Baron-Cohen, S. (2013). Exploring Autistic Traits in Anorexia: A Clinical Study. Molecular Autism, 4, 44.
[55] Tiller, J. M., Sloane, G., Schmidt, U., Troop, N., Power, M., & Treasure, J. L. (1997). Social Support in Patients with Anorexia Nervosa and Bulimia Nervosa. International Journal of Eating Disorders, 21, 31-38.
[56] Troop, N. A., & Bifulco, A. (2002). Childhood Social Arena and Cognitive Sets in Eating Disorders. British Journal of Clinical Psychology, 41, 205-211.
[57] Uljarevic, M., & Hamilton, A. (2013). Recognition of Emotions in Autism: A Formal Meta-Analysis. Journal of Autism and Developmental Disorders, 43, 1517-1526.
[58] Williamson, S., Craig, J., & Slinger, R. (2008). Exploring the Relationship between Measures of Self-Esteem and Psychological Adjustment among Adolescents with Asperger Syndrome. Autism, 12, 391-402.
[59] Wilkinson, R. G., & Marmot, M. G. (2003). Social Determinants of Health: The Solid Facts. Copenhagen: World Health Organisation.
[60] Zucker, N., Wagner, H. R., Merwin, R., Bullik, C. M., Moskovich, A., Keeling, L., & Hoyle, R. (2014). Self-Focused Attention in Anorexia Nervosa. International Journal of Eating Disorders, Early View.

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