ETD

• anorexia nervosa
• autism spectrum disorder
• autistic traits
• eating disorders
• female phenotype of autism
• loss events
• maladaptive coping
• social camouflaging
• trauma and stress-related symptoms

Background: Recent advances in the field of psychopathology have increasingly focused on the identification of undiagnosed Autism Spectrum Disorder (ASD) and subthreshold autistic traits (ATs) within non-clinical and clinical populations. Current literature has emphasized the substantial phenotypic and cognitive overlap between ASD and eating disorders (EDs), particularly anorexia nervosa (AN), supporting the conceptualization of EDs as female autism spectrum phenotype. Converging evidence indicates shared neurocognitive dysfunctions between ASD and EDs, including cognitive rigidity, impaired theory of mind (ToM), and ruminative thinking. Moreover, a growing body of empirical research has highlighted a heightened susceptibility to post-traumatic stress disorder (PTSD) symptoms in individuals presenting with either ASD/ATs or EDs. Notably, both social camouflaging behaviours, defined as compensatory strategies aimed at masking social difficulties, and disordered eating patterns have been increasingly associated with the female phenotype of autism spectrum conditions.

Aims: This study aimed to explore the relationship between social camouflaging and trauma and stress-related symptoms in individuals with EDs. Despite emerging theoretical links, this specific association remains markedly under-investigated in the current scientific literature.

Methods: Sixty-seven outpatients (62 females and 5 males) diagnosed with an eating disorder, according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), were recruited from the Psychiatric Department of the Azienda Ospedaliera Universitaria Pisana (AOUP). To evaluate, through a dimensional approach, the broad spectrum of both subthreshold and overthreshold symptomatology, all participants were assessed using the Adult Autism Subthreshold Spectrum (AdAS Spectrum) for the evaluation of ATs, the Trauma and Loss Spectrum – Self Report (TALS-SR) for the assessment of trauma and loss-related symptoms, the Camouflaging Autistic Traits Questionnaire (CAT-Q) for the evaluation of social camouflaging strategies, and the Eating Disorder Inventory-2 (EDI-2) for the investigation of disordered eating behaviours.

Results: A total of 36 participants (53.7%) fulfilled the symptomatology criteria for PTSD according to TALS-SR. Individuals in the PTSD group reported significantly higher total scores on both the TALS-SR and CAT-Q questionnaires, including all CAT-Q subscales. Moreover, participants with PTSD scored significantly higher on the EDI-2 total score, particularly in the domains of Ineffectiveness, Interoceptive Awareness, Impulsivity, and Social Insecurity. No significant differences were found in the distribution of specific eating disorder diagnoses between the PTSD and No-PTSD groups. In addition, CAT-Q scores were significantly and positively correlated with TALS-SR scores. Lastly, the study revealed that, among patients with EDs, the presence of trauma and stress-related symptoms was a significant predictor of greater use of social camouflaging strategies. In particular, the Maladaptive Coping domain of the TALS-SR emerged as a significant positive predictor of social camouflaging behaviours, whereas the Loss Events domain was identified as a significant negative predictor.

Conclusions: The results of the present study highlight a significant association between social camouflaging and post-traumatic symptomatology in a sample of individuals with EDs. Furthermore, post-traumatic symptoms and in particular maladaptive coping emerged as significant positive predictors of a greater use of social camouflaging strategies. These findings underscore the importance and necessity of adopting a multidimensional diagnostic framework in clinical settings, one that actively assesses not only eating-related symptoms, but also trauma history and neurodivergent profiles, including ATs and social camouflaging. This approach may support the development of integrated and personalized therapeutic interventions.