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What relationship, if any, exists between the diagnosis of eating disorders and that of attention-deficit/ hyperactivity disorder (ADHD) in females?
May 2 2009
Millions of Americans suffer from either attention-deficit/hyperactivity disorder or some form of disordered eating, and the number of new diagnoses is increasing each year. According to Gillberg, et al. (2004), comorbidities in ADHD patents are a widespread and critical aspect of the disorder, and the same can be said for eating disorders. Both illnesses are often found alongside similar comorbid conditions, including obsessive-compulsive disorder, depression, substance abuse, and bipolar disorder, and several recent case studies have found ADHD and eating disorders to be comorbid conditions of one another (Gillberg, 2004; http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/psychiatry/eating-disorders/). Because the two conditions are growing increasingly commons and can share certain symptoms, including impulsivity and low self esteem, it is important to analyze the correlation and overlap between these two disorders (Dukarm, 2005).
Attention-deficit/ hyperactivity disorder is one of the most common neurobiological disorders with which children are diagnosed (http://www.cdc.gov/ncbddd/adhd/facts.html). ADHD has two subtypes: inattentive and hyperactive/impulsive. Those suffering from the former subtype are often forgetful, easily distracted, and unorganized, while the latter is marked by extreme restlessness, anxiety, and impulsive actions like interrupting others; many are diagnosed with a combination of the two subtypes, dubbed ADHD-C (http://www.cdc.gov/ncbddd/adhd/facts.html).
The disorder can be treated in a variety of ways, including behavioral therapy, family therapy, special education courses for school-aged children, and medication. Many doctors recommend a combination of the various therapies, but medication is one of the most often used, and fairly controversial, treatment methods. Two of the most common prescription drugs used in the treatment of ADHD include antidepressants or stimulants, such as methylphenidates (Ritalin, Concerta, etc.) and amphetamines (Adderall), and are used to alter how the brain processes dopamine and norepinephrine (http://www.help4adhd.org/en/treatment/medical/WWK10). While medicine is effective in controlling ADHD symptoms in many people, it is also a highly abused type of prescription; those without ADHD often take such medicines for their stimulant qualities and appetite suppression.
Eating disorders affect well over 30 million Americans, and more than 11 million suffer from either anorexia nervosa or bulimia nervosa (http://www.sc.edu/healthycarolina/pdf/facstaffstu/eatingdisorders/EatingDisorderStatistics.pdf). While most cases of anorexia and bulimia are in young to middle-aged females – 40 percent of newly identified anorexia cases are in adolescent girls, and bulimia cases in young women have tripled over the last three years – eating disorders can affect people of all ages, ethnicities, and genders (http://www.sc.edu/healthycarolina/pdf/facstaffstu/eatingdisorders/EatingDisorderStatistics.pdf). Additionally, eating disorders are the most deadly of any mental illness, but only one in every ten people afflicted will receive sufficient treatment for her condition (http://www.state.sc.us/dmh/anorexia/statistics.htm). With the entertainment and advertisement industries perpetuating and increasingly slender ideal of beauty in a consumer society focused on excess and gluttony, it is no wonder that in recent years, eating disorders have received increasing amounts of attention from all.
There are several types of eating disorders recognized and treated by doctors. Anorexia nervosa and bulimia nervosa are two of the most frequently discussed. According to the DSM-IV, anorexia nervosa is characterized by refusal to maintain at least 85 percent of one’s expected body weight, extreme fear of gaining weight, and amenorrhea when applicable; anorexics may maintain this state by either binging and purging (binge/purge subtype) or by restricting food without episodes of binging (restricting subtype) (http://eatingdisorderrecovery.com/dsmiv/). On the other hand, those with bulimia nervosa binge and purge – by methods including self-induced vomiting, fasting, excessive exercise, or laxative abuse – several times each week because of weight-related concerns; however, bulimics do not meet certain criteria for anorexia, including low Body Mass Index (BMI) or amenorrhea, when applicable (http://eatingdisorderrecovery.com/dsmiv/). Additionally, those with anorexia are more apt to have anxious, dependent, and avoidant personalities, but bulimics are typically more impulsive in nature and are often emotionally unstable (http://adam.about.com/reports/000049_1.htm). There is another, less known category of eating disorders called EDNOS (Eating Disorders not Otherwise Specified) in which the patient only meets some of the criteria for the aforementioned eating disorders or displays other abnormal eating habits (http://eatingdisorderrecovery.com/dsmiv/).
While there is a common belief that eating disorders are used only to lose weight, this is a large misconception. Over 25 million Americans currently suffer from Binge Eating Disorder, which often causes excessive weight gain and obesity, rather than alarming thinness (http://www.sc.edu/healthycarolina/pdf/facstaffstu/eatingdisorders/EatingDisorderStatistics.pdf). Binge eaters are classified by eating much more food than the average person in a given period of time several times each week. These episodes are marked by the binger feeling a loss of control over her food intake, eating rapidly or until uncomfortably full, eating alone, and/or feeling guilty after the binge (http://www.realmentalhealth.com/eating_disorders/binge_eating.asp). Unlike bulimia or the binge/purge subtype of anorexia, these binges are not followed by compensatory purging behaviors, and therefore frequently lead to weight gain or severe obesity.
Correlations between ADHD and Eating Disorders
General Prevalence of ADHD in Eating Disorders
Clinical Study I
Yates, et al. (2009) conducted a study of 189 females eating disorder inpatients to determine the prevalence of ADHD among women with various eating disorders. Through structured clinical interviews for DSM-IV diagnosis and ADHD interviews from the Multi-International Psychiatric Interview, Yates determined only 5.8 percent of the population met standardized diagnostic criteria for ADHD; however, 21 percent showed multiple ADHD symptoms (2009). Inattention was the most frequently reported ADHD symptom in non-ADHD subjects, and significantly correlated with higher BMI, lower self-satisfaction, higher levels of depression and bulimia nervosa symptoms (Yates, 2009). In addition, ADHD symptoms in subjects that did not meet diagnostic criteria for the disorder often did not have a childhood onset, indicating that these symptoms may be cause by a different psychological disorder (Yates, 2009). Moreover, of those diagnosed with ADHD, only one subject met diagnostic criteria for anorexia, restricting subtype, while the other nine were diagnosed with bulimia or anorexia, binge-purge subtype (Yates, 2009). Though the study failed to show an increased rate of ADHD among eating disorder patients, there is a clear prevalence of bulimia and binge-purge anorexia over restricting anorexia in this population (Yates, 2009).
While the sample size in this study was sufficiently large, the percentage of the population diagnosed with ADHD was very small. A larger study could have allowed for further analysis and distinction between eating disorder subgroups after the ADHD diagnosis (Yates, 2009). Additionally, the proportion of eating disorder patients with ADHD was not compared to a control group without eating disorders, decreasing the value of the data found in the results. Furthermore, retrospective interviews are prone to underreporting, and therefore the proportion of subjects with ADHD could possibly be underrepresented. The retrospective interview was self-reported, and consulting scholastic records or parent and teacher interviews could have provided a more accurate representation of childhood symptoms (Yates, 2009). One significant strength of the study was that it was one of the only ones of its type to differentiate between the onset of ADHD symptoms during childhood and later onset of symptoms, which may indicate a different psychological disorder and not necessarily prevalence of ADHD. Though a control group would have made the study much more sound, there is no reason to believe that the findings are drastically incorrect.
Clinical Study I
Marked by impulsivity and unstable emotions, those with bulimia nervosa share many of the same symptoms as the ADHD-C. Biederman, et al. conducted a five-year study of 140 girls, between ages 6 and 18, with ADHD and an equal number of comparable girls in a control group (2007). The study used structured clinical interviews per the DSM-IV conducted by psychologists who were blind to the subjects’ diagnoses (Biederman, 2007). Results from the baseline and follow up assessments show that 16 percent of females with ADHD suffered from an eating disorder, as opposed to only 5 percent in the control group (Biederman, 2007). Of those with an eating disorder, 50 percent of girls in the ADHD group were diagnosed with bulimia nervosa, while 20 percent of those in the control group had bulimia (Biederman, 2007). Biederman’s study concluded that females with ADHD are 3.6 times more likely to meet criteria for an eating disorder than those without ADHD and are 5.6 times more likely to have bulimia nervosa (2007).
While height was corrected for age, weight was corrected for both height and age, and a control group was included, there were limitations to this study. For one, all subjects had been referred either from an outpatient list at the Massachusetts General Hospital or through the medical records of a health maintenance organization, so it is possible that this sample was not representative of the average population of girls with ADHD. Furthermore, the subjects were almost entirely white, so data may differ for females of other ethnic backgrounds; all subjects were also female. Lastly, DSM-IV was not completed upon the onset of the study, so in baseline assessments only, subjects with eating disorders were diagnosed based on DSM-III criteria plus supplementary questions to help make correct DSM-IV diagnoses; however, there is a 93% overlap between the diagnoses criteria in the two editions, so would cause minimal, if any, variance in the results (Biederman, 2007). Overall, the research method was sound, and while it could be improved by taking a more random population sample, the results strongly indicate increased cases of bulimia among ADHD patients; in addition, the fact that ADHD patients were diagnosed during childhood indicates that the causes of inattention and other symptoms are more likely related to ADHD than other extraneous causes, which further strengthens the study.
Clinical Study II
Mikami, et al. (2009) conducted a similar study in which a group of 432 male and female youths with ADHD-C were compared to a local normative comparison group of 264 young males and females through both at 24-month baseline analysis and 36-month, 6-year, and 8-year follow up assessments to determine if the subjects met criteria for bulimia nervosa. The study found that both males and females with ADHD were much more likely than their control group counterparts to have poor body image and show symptoms of bulimia during adolescence, and females were more likely to show bulimia symptoms than males within this group (Mikami, 2009). In addition, parent-reported impulsivity symptoms showed up to an 80 percent correlation with the child meeting some or all criteria for bulimia, for girls in particular; conversely, inattention and hyperactivity showed drastically less correlation with the development of bulimia at any point in the study (Mikami, 2009). Mikami, et al. (2009) found through their study that the impulsive tendencies of those with ADHD and their inability to regulate their responses to negative outcomes are two of the strongest factors that link the prevalence of ADHD and the development of bulimia, and that bulimia was possibly a mechanism of coping with frustration or disappointment.
This study presents a fairly accurate depiction of the uncontrolled impulsivity common to both ADHD and bulimia and confirms other studies’ findings. Again, the early onset of ADHD symptoms reduces the likeliness that the disordered eating is caused by a different comorbid disorder. However, results could have been more accurate had subjects with only one ADHD subtype been included to more accurately distinguish impulsivity from inattentiveness or hyperactivity as a factor related to or predictive of bulimia. Additionally, since Mikami claimed that binging was predicted to be a coping mechanism among ADHD-C subjects, this claim should be further validated by the inclusion of binge eating disorder patients with ADHD-C in future studies (2009). An additional way to justify the link between the impulsivity of ADHD-C and bulimia would be to include a child self-report at some point during the study to evaluate the subject’s body image and own perspective of eating habits and coping mechanisms. Furthermore, the study was not controlled for outlying factors, such as childhood maltreatment or comorbid mental illnesses, both of which are more common among ADHD and eating disorder patients. These factors may have contributed to the correlation between bulimia and ADHD rather that evaluating the correlation between only those two illnesses. Despite the aforementioned limitations of the study, it does present a very sound argument that particularly in females, the risk of developing bulimia nervosa was higher for those with ADHD-C than for those without impulsivity related to ADHD.
Case Study I
In the first study to date focusing on both ADHD and bulimia nervosa, Schweickert, et al. (1997) presented a case study of a 25-year-old Caucasian female, diagnosed with ADHD at age 7, who is seeking a reevaluation of and new treatment for her ADHD. At age 12, the patient stopped her use of methylphenidate to treat her ADHD symptoms, and began binging and purging shortly after to cope with her parents’ divorce (Schweickert, 1997). The UCLA Psychopharmacology Clinic prescribed the patient 10mg methylphenidate per day, and shortly increased the treatment to 15mg. Schweickert (1997) reported that while the methylphenidate had no adverse effect on her appetite, her bingeing immediately ceased due to increased concentration and decreased restlessness. The study concluded that binge eating may be caused by impulsivity in ADHD patients and is potentially a compensatory means by which to cope with the frustration ADHD causes (Schweickert 1997). Schweickert additionally concluded it might be beneficial in the future to test individuals with bulimia for ADHD, as that could be the true cause behind the eating disorder.
As the first study of its type, Schweickert’s case study was effective in addressing the possible comorbidity between bulimia nervosa and ADHD, and prompted others to expand upon that claim through further research. However, there were various confounding circumstances, including the patient’s history of drug use in her teens. However, the study does indicate that her desire to binge decreased after taking medication, rather than the patient merely losing her appetite as a side effect. This indicates that treatment of ADHD could possibly control the psychological causes behind bulimia, rather than suppressing one’s appetite or inducing nausea as a side effect. Schweickert, et al. (1997) present a plausible means to believe that bulimia could be caused by ADHD, and that medical treatment of ADHD could also treat bulimia, through the results of this case study. A future clinical study testing a larger sample size could further support this assertion, as a case study cannot accurately represent a population; this is a limitation found in all case studies, in which there is a tradeoff between a large, representative sample in order to pay close attention to detail in one specific subject.
Case Study II
Sokol, et al. (1999) discusses 2 case studies regarding the treatment of bulimia nervosa with methylphenidate, which is most commonly used for the control of ADHD symptoms. She asserts that those with both bulimia nervosa and a cluster-b personality disorder do not respond to antidepressant medication because their combined symptoms resemble ADHD symptoms, regardless of whether the subject has had a professional diagnosis of ADHD (Sokol, 1999). In the study, two women, ages 20 and 38, with a history of eating disorders and cluster-b personality disorders were administered various amounts of methylphenidate and found a drastically reduced desire to binge and subsequently purge (Sokol, 1999). The 20-year-old subject reported that her bulimia symptoms disappear entirely, except for 2 instances during which she did not take her medicine (Sokol, 1999). Similarly, the 38-year-old subject responded positively to methylphenidate, and reported that her bulimia symptoms only resurfaced at night as a rebound after the methylphenidate’s effects subsided (Sokol, 1999). Though never officially diagnosed with ADHD, both subjects experienced a decrease in ADHD symptoms, including impulsivity and inattentiveness, according to baseline and follow up scores on the Conners ADHD symptom scale (Sokol, 1999).
Though this study does not show any direct comorbidity between bulimia nervosa and ADHD, there is a clear correlation between the two as methylphenidate effectively reduced, and at times almost eliminated, symptoms of both disorders in each subject. However this result is left mainly to interpretation and only presents a possible correlation between the two without asserting a concrete relationship, as ADHD was not one of the variables tested in the case study. Therefore significant weakness in using this study as a basis for linking ADHD as a comorbidity of bulimia, or vise versa, is that the study was designed to show the effect of an ADHD treatment on relieving bulimia symptoms in subjects; it was not designed to show correlation between the two disorders themselves. That being said, the most one can infer from this data is that the two may share some commonality (possibly impulsivity) that can be reduced by the use of psychostimulants, and one can not necessarily conclude that the occurrence bulimia and ADHD are related in patients.
A further limitation to the study is that the subjects had histories of secondary personality disorders, from cluster-b personality disorders to anxiety and depression in the case of subject 2. These confounding variables were not controlled in the study and may have altered the data as opposed to subjects with only bulimia nervosa and ADHD symptoms. Another control to enhance the reliability of the study could be the analysis of methylphenidate on reducing bulimia symptoms and bingeing in subjects with little no significant ADHD symptoms. This control could help decipher between whether the stimulant medication merely can serve several roles or if ADHD and bulimia are actually correlated in some manner by seeing if methylphenidate effectively reduces bulimia symptoms in non-ADHD patients. This study does have its merits and certainly provides evidence that the two disorders are directly related in the subjects’ reactions to methylphenidate. However, the lack of a control group in the study and the extraneous variables make drawing a conclusion directly from this study less reliable than it could be with a more sound design. Furthermore, the variable measured, while related to comorbid instances in bulimia and ADHD, is slightly different and one must speculate too much from the study to draw a valid conclusion about any comorbid occurrences with the 2 disorders; we can only see here that there is good reason to believe they may be related.
Case Study III
This next case study evaluates 5 bulimic females and their reactions to psychostimulants as a treatment for their bulimia nervosa symptoms. Dukarm (20050 reported that all five girls had a BMI within the normal range and had symptoms consistent with ADHD, inattentive type. Two of the subjects met the DSM-IV diagnostic criteria for ADHD, inattentive subtype. All five subjects were prescribed dextroamphetamine sulfate, which successfully reduced binges and increased moods and attention in each subject according to self-reported information (Dukarm, 2005). Dukarm asserts that ADHD, inattentive subtype, may be under diagnosed due to its less disruptive nature; females are more likely to have this form of ADHD and are therefore less likely to be diagnosed, which may cause low self esteem and even depression (2005). These factors, along with the general impulsive and inattentive nature of ADHD patients leads Dukarm to believe that bulimia could potentially manifest itself from untreated ADHD symptoms (2005). By using psychostimulants to decrease the impulsivity and distractibility caused by ADHD, along with the low self-esteem that may follow, one may eliminate most significant risk factors from ADHD. This suggests that some, if not all, cases of bulimia could result from ADHD, and by eliminating ADHD the eating disorder can be suppressed (Dukarm, 2005).
This case study provided a well-controlled analysis of the effects of ADHD on bulimia nervosa patients, showing a fairly distinct relation between the two. The subjects were all given meal-planning guidance and nutritional education upon starting there medicine, which may have increased the effects of the medicine more so than without the additional therapy, thus overstating the correlation between ADHD and bulimia (Dukarm, 2005). This is unlikely, however, as four patients had previously received psychotherapy for bulimia symptoms and found no improvement (Dukarm, 2005). Otherwise this study was sound and the variables measured were highly relevant. While specific cases cannot speak for an entire population, this study gives one reason to believe reducing ADHD symptoms will suppress bulimia nervosa. A larger, more representative clinical study could further confirm the findings from this case study and test Dukarm’s hypothesis that bulimia, in some cases, is a symptom of ADHD.
Binge Eating Disorder
Clinical Study I
Davis, et al. (2009) compared the ADHD symptoms in 60 adults, a majority of whom were female, that met DSM-IV criteria for binge eating disorder with that of two comparable control groups; one control group of 60 was comprised of obese non-bingers while the other group had 61 adults with a normal BMI. No subjects in the control groups met or had previously met criteria for any eating disorders (Davis, 2009). Through measurement of the Wender Utah Rating Scale for childhood ADHD symptoms and the Conners’ Adult ADHD Rating Scale – Self-report Screening Version, Davis (2009) found that the probability of a subject being in the normal control group, as opposed to the obese control or binge eating groups, decreases exponentially and approaches zero as the prevalence of ADHD symptoms increases. Thus, one may infer that ADHD symptoms have an inverse relationship on normal weight and controlled eating habits, and that those with ADHD symptoms are more prone to obesity and excessive eating. However, even though the probability of binge eating disorder was drastically higher than that of obesity not caused by an eating disorder on all three Conners’ ADHD scales – there was a minimal difference between the two on the WURS – the difference was not statistically significant enough to distinguish the two (Davis, 2009). Therefore, although there is an apparent trend showing that ADHD is most prevalent specifically in binge eaters, one can only conclude from this data that ADHD symptoms have a positive correlation to obesity, regardless of eating disorder diagnosis (Davis, 2009).
This study, while not indicating that ADHD is necessarily related to disordered eating, does bring up an interesting relationship to obesity. Just as the studies regarding bulimia concluded, those with ADHD may have issues with impulsivity and inattention, and therefore may eat when they are not hungry or be more prone to pick unhealthy foods as a consequence of poor planning skills and disregard of consequences. In addition, Davis (2009) suggested those with severe inattentiveness and poor impulse control may respond to external stimuli, such as seeing or smelling food, rather than their appetites, when eating. However, there are many limitations to the study, including the high prevalence of depression in binge eaters, which has symptoms that could easily be mistaken for ADHD (Davis, 2009). Only the control groups were screened and controlled for past psychiatric history, so the study could be improved if all subject groups were controlled for extraneous disorders or illnesses, as this may have a pronounced effect on the prevalence of ADHD symptoms (Davis, 2009). Furthermore, ADHD prevalence was determined only by the two diagnostic tests, and this method of diagnosis could be strengthened by the inclusion of psychologist conducted diagnostic interview or retrospective childhood evaluation. A future study on the differences between only a group of obese binge eaters and an obese control group to further evaluate them for any significant differences in the prevalence of ADHD may prove useful, as there was an apparent, but insignificant increase in the probability for subjects with severe ADHD to have binge eating problems. Since the two groups had a similar prevalence of childhood ADHD symptoms, but the binge eaters showed more severe symptoms during adulthood, it could be possible that there is an outlying cause of both this discrepancy and the eating disorder, as ADHD symptoms are usually consistent from childhood. Otherwise, the study was conducted soundly and provided accurate and relevant information distinguishing those with ADHD as having a higher probability of being obese. This study indicates that ADHD screening could be useful when working with obese patients; furthermore, it suggests therapy or treatment for ADHD may prove beneficial in managing weight in obese patients (Davis, 2009).
Clinical Study II
Mattos, et al. (2004) conducted clinical study of 107 adults who were screened for both eating disorder symptoms and ADHD. 86 of the subjects fulfilled DSM-IV criteria for an ADHD diagnosis after evaluation on the ADHD childhood symptoms scale, and of those diagnosed with ADHD, 9 were diagnosed with an eating disorder (Mattos, 2004). Seven of the 9 with both an eating disorder and ADHD had binge eating disorder, while one had bulimia nervosa and the other had a diagnosis not otherwise specified by the DSM-IV; the majority of those with binge eating disorder were female (Mattos, 2004). Mattos concluded that the 8.13 percent prevalence of binge eating disorder in ADHD patients is drastically greater than that of the general population, which is approximately 2.6 percent (2004). This provides a basis to conclude that there is increased chance of comorbidity with binge eating disorder and ADHD in adult females.
Although the study indicates more research should be done regarding binge eating and ADHD, its results cannot be considered completely accurate. For one, Mattos compared the prevalence of binge eating disorder in a small sample of ADHD subjects with the entire population. This huge discrepancy in sample sizes renders the comparison pretty inaccurate, and the study could be improved by the inclusion of a non-ADHD control group of similar size. The group of those without ADHD in this study was approximately one fourth as large as the ADHD group, and it would therefore be hard to compare them as well, as it is too small of a sample size. Because only 9 subjects had eating disorders, it is hard to distinguish between eating disorder subgroups, as the sample is too limited; an overall larger study could increase this sample, along with the others, and provide more accurate data. Moreover, each subject with an eating disorder had other comorbid disorders, including depression and substance abuse; since these disorders were not controlled in the study, they may have presented a confounding effect on the data collected. In general, this study is severely limited and does not provide sound enough research for one to arrive at a definitive conclusion about prevalence of binge eating disorder in those with ADHD.
Discussions and Conclusion
Based on the cited literature, it seems as if there is a relationship between bingeing-related eating disorders and incidence of ADHD in females. However, the research does provide conflicting evidence, with some studies indicating that there is a comorbid relationship between eating disorders and ADHD and others contradicting that. The studies conducted by Biederman et al. (2007), Mikami et al. (2009), Schweickert (1997), and Dukarm (2005) provide sound, reliable research that indicates an increased probability of comorbidity between ADHD and bulimia nervosa in females. While Yates’s (2009) study does not indicate any significantly elevated occurrence of ADHD in eating disorder patients, his research does indicate that ADHD may be more common in binge-purge eating disorders than in restrictive eating disorders. On the other hand, none of the cited research indicated that binge eating disorder had any particularly obvious comorbidity with ADHD. Additionally, none of the studies indicated any significant relationship between anorexia nervosa or eating disorders not otherwise specified and ADHD symptoms.
Another interesting conclusion this analysis led to was that medicine intended to treat ADHD may have a large effect in suppressing the desire to binge in bulimics. This common treatment may indicate some psychiatric commonalities between the two disorders, which would increase their likeliness of being comorbid conditions. Another interpretation is that bulimia can be a symptom of untreated ADHD, and by pharmaceutically suppressing the ADHD symptoms, bulimia symptoms will, too, subside. The off-label use of ADHD medication to suppress bulimia symptoms seems to be a promising solution, according to the case studies; when combined with psychotherapy, it has the potential to hinder binge-purge activity while a patient is working on improving her psychological state.
Both the comorbid occurrences of ADHD and bulimia and the treatment of bulimia with ADHD medication are two promising proposals that would benefit from future research. Eating disorders are a highly misunderstood and difficult to treat problem, and if these ideas prove effective and safe, many people suffering from bulimia could be helped more effectively, and the disorder itself could be prevented to an extent. An additional idea that should be researched in the future is the comparison of ADHD diagnoses in patients with bulimia and patients with binge eating disorder to differentiate between characteristics of those who purge and those who do not. Additionally, any future research needs to take into account that ADHD symptoms must be apparent at an early age for a true diagnosis and that late-onset ADHD symptoms may likely be another underlying psychological cause, such as depression, anxiety, or other personality disorders.
Biederman, J., Ball, S. W., Monuteaux, M. C., Surman C. B., Johnson, J. L., et al. (2007). Are girls with ADHD at risk for eating disorders? Results from an controlled, five-year prospective study. Journal of Developmental and Behavioral Pediatrics, 28(4), 302-307. Retrieved from Ovid SP.
Davis, C., Patte, K., Levitan, R. D., Carter, J., Kaplan, A. S., et al. (2009). A psycho-genetic study of associations between the symptoms of binge eating disorder and those of attention deficit (hyperactivity) disorder. Journal of Psychiatric Research, 43(7), 687-696. Retrieved from ScienceDirect.
Dukarm, C. P. (2005). Bulimia Nervosa and Attention Deficit Hyperactivity Disorder: A Possible Role for Stimulant Medication. Journal of Women’s Health, 14(4), 345-350. Retrieved from Pubmed Central database.
Gillberg, C., Gillberg, I. C., Rasmussen, P., Kadesjö, B., Söderström, H., et al. (2004). Co-existing disorders in ADHD – implications for diagnosis and intervention. European Child & Adolescent Psychiatry, 13(1), 80-92. Retrieved from Pubmed Central database.
Mattos, P., Saboya, E., Ayrao, V., Segenreich, D., Duchesne, M., et al. (2004). Comorbid eating disorders in a Brazilian Attention- Deficit/Hyperactivity Disorder adult clinical sample. Brazilian Psychiatric Review, 26(4), 248-250. Retrieved from Google Scholar.
Mikami, A. Y., Hinshaw, S. P., Arnold, L.E, Hoza, B., Hechtman, L., et al. (2009). Bulimia nervosa symptoms in the multimodal treatment study of children with ADHD. International Journal of Eating Disorders, in press. Retrieved from Wiley InterScience online database.
Schweickert, L. A., Strober, M. & Moskowitz, A. (1997). Efficacy of Methylphenidate in Bulimia Nervosa Comorbid with Attention-Deficit Hyperactivity Disorder: A Case Report. International Journal of Eating Disorders, 21(3), 299-301. Retrieved from Wiley InterScience online database.
Sokol, M. S., Gray, N. S., Goldstein, A. & Kaye, W. (1999). Methylphenidate Treatment for Bulimia Nervosa Associated with a Cluster B Personality Disorder. International Journal of Eating Disorders, 25(2), 233-237. Retrieved from Wiley InterScience online database.
Yates, W. R., Lund, B. C., Johnson, C., Mitchell, J. & McKee, P. (2009) Attention-Deﬁcit Hyperactivity Symptoms and Disorder in Eating Disorder Inpatients. International Jounal of Eating Disorders, 42(4), 375-378. Retrieved from Pubmed Central database.
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