Are treatment results for eating disorders affected by ADHD symptoms? A one-year follow-up of adult females

A Female-Specific Treatment Group for ADHD-Description of the Programme and Qualitative Analysis of First Experiences

Background: The diagnostics and treatment of attention-deficit/hyperactivity disorder (ADHD) in women remain insufficient. Fluctuations of reproductive hormones during the premenstrual period, postpartum period, and (peri)menopause are neglected, even though they impact ADHD symptoms and associated mood disorders. Therefore, we created a female-specific treatment group for women with ADHD and premenstrual worsening of ADHD and/or mood symptoms. Methods: We describe the group programme and underlying rationale, offering a qualitative analysis of the participants' evaluation. Results: The seven bi-weekly sessions foreground the menstrual cycle and address several ADHD-specific topics in relation to this cyclical pattern. Concurrently, women track their menstrual cycle and (fluctuating) ADHD and mood symptoms with an adjusted premenstrual calendar. In total, 18 women (25-47 years) participated in three consecutive groups. We analysed the evaluation of the last group. Participants experienced the group as a safe and welcoming space. Recognition was valued by all. The topics discussed were deemed valuable, and the structure suited them well. Completing the premenstrual calendar augmented the awareness and recognition of individual cyclical symptoms. A lifespan approach increased self-understanding. Participants took their menstrual cycle more seriously, prioritising self-acceptance and self-care. Conclusions: Exploring a cyclical approach in a group setting seems to be a positive addition to treatment for female ADHD.

The relationship between anorexia nervosa and bulimia nervosa, attention deficit/hyperactivity disorder, and suicidality in college students

OBJECTIVE

This study aimed to assess the association between anorexia nervosa (AN), bulimia nervosa (BN), attention deficit/hyperactivity disorder (ADHD), and associated impairments (e.g., suicidality).

METHODS

A secondary data analysis of the American College Health Association-National College Health Assessment IIc (Fall 2015-Spring 2019) was conducted to assess the prevalence of comorbid anorexia or bulimia + ADHD, symptoms, and impairments among college student (N = 342,432; M_age  = 20.39, SD = 1.88). Logistic regressions were used to compare eating disorder symptomology, treatment utilisation, and suicidality among college students.

RESULTS

Compared to college students without ADHD, college students with ADHD were 18.30× more likely to be diagnosed with anorexia or bulimia and reported greater use of weight loss techniques (p's < 0.001). College students with comorbid anorexia or bulimia + ADHD reported higher rates of dieting to lose weight (aOR = 1.27, 95% CI: 1.12, 1.43, p < 0.001) and treatment utilisation (aOR = 1.30, 95% CI: 1.06, 1.50, p < 0.001) compared to college students with AN or BN only. The highest level of suicidality was reported in college students with the comorbid AN or BN + ADHD.

CONCLUSION

Elevated eating disorder symptoms and comorbidity is found among college students with ADHD. Increased screening and prevention for anorexia and bulimia is needed among young adults with ADHD to enhance care for those with these eating disorders.

Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature

BACKGROUND

Eating disorders (EDs) are potentially severe, complex, and life-threatening illnesses. The mortality rate of EDs is significantly elevated compared to other psychiatric conditions, primarily due to medical complications and suicide. The current rapid review aimed to summarise the literature and identify gaps in knowledge relating to any psychiatric and medical comorbidities of eating disorders.

METHODS

This paper forms part of a rapid review) series scoping the evidence base for the field of EDs, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for English-language studies focused on the psychiatric and medical comorbidities of EDs, published between 2009 and 2021. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised.

RESULTS

A total of 202 studies were included in this review, with 58% pertaining to psychiatric comorbidities and 42% to medical comorbidities. For EDs in general, the most prevalent psychiatric comorbidities were anxiety (up to 62%), mood (up to 54%) and substance use and post-traumatic stress disorders (similar comorbidity rates up to 27%). The review also noted associations between specific EDs and non-suicidal self-injury, personality disorders, and neurodevelopmental disorders. EDs were complicated by medical comorbidities across the neuroendocrine, skeletal, nutritional, gastrointestinal, dental, and reproductive systems. Medical comorbidities can precede, occur alongside or emerge as a complication of the ED.

CONCLUSIONS

This review provides a thorough overview of the comorbid psychiatric and medical conditions co-occurring with EDs. High psychiatric and medical comorbidity rates were observed in people with EDs, with comorbidities contributing to increased ED symptom severity, maintenance of some ED behaviours, and poorer functioning as well as treatment outcomes. Early identification and management of psychiatric and medical comorbidities in people with an ED may improve response to treatment and overall outcomes.

The potential role of stimulants in treating eating disorders

BACKGROUND

Many individuals with eating disorders remain symptomatic after a course of psychotherapy and pharmacotherapy; therefore, the development of innovative treatments is essential.

METHOD

To learn more about the current evidence for treating eating disorders with stimulants, we searched for original articles and reviews published up to April 29, 2021 in PubMed and MEDLINE using the following search terms: eating disorders, anorexia, bulimia, binge eating, stimulants, amphetamine, lisdexamfetamine, methylphenidate, and phentermine.

RESULTS

We propose that stimulant medications represent a novel avenue for future research based on the following: (a) the relationship between eating disorders and attention deficit/hyperactivity disorder (ADHD); (b) a neurobiological rationale; and (c) the current (but limited) evidence for stimulants as treatments for some eating disorders. Despite the possible benefits of such medications, there are also risks to consider such as medication misuse, adverse cardiovascular events, and reduction of appetite and pathological weight loss. With those risks in mind, we propose several directions for future research including: (a) randomized controlled trials to study stimulant treatment in those with bulimia nervosa (with guidance on strategies to mitigate risk); (b) examining stimulant treatment in conjunction with psychotherapy; (c) investigating the impact of stimulants on "loss of control" eating in youth with ADHD; and (d) exploring relevant neurobiological mechanisms. We also propose specific directions for exploring mediators and moderators in future clinical trials.

DISCUSSION

Although this line of investigation may be viewed as controversial by some in the field, we believe that the topic warrants careful consideration for future research.

Negative Affectivity and Emotion Dysregulation as Mediators between ADHD and Disordered Eating: A Systematic Review

Attention-Deficit/Hyperactivity Disorder (ADHD) is associated with disordered eating, especially addictive-like eating behavior (i.e., binge eating, food addiction, loss of control overeating). The exact mechanisms underlying this association are unclear. ADHD and addictive-like eating behavior are both associated with negative affectivity and emotion dysregulation, which we hypothesized are mediators of this relationship. The purpose of this systematic review was to review the evidence related to this hypothesis from studies assessing the relationship between childhood or adulthood ADHD symptomatology, negative affectivity, emotion dysregulation and addictive-like eating behavior. The systematic review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) recommendations. The literature search was conducted in PubMed and PsycINFO (publication date: January 2015 to August 2020; date of search: 2 September 2020). Out of 403 potentially relevant articles, 41 were retained; 38 publications reported that ADHD and disordered eating or addictive-like eating behavior were significantly associated, including 8 articles that suggested a mediator role of negative affectivity or emotion dysregulation. Sixteen publications reported that the association between ADHD symptomatology and disordered eating or addictive-like eating behavior differed according to gender, eating behavior and ADHD symptoms (hyperactivity, impulsivity and inattention). We discuss the practical implications of these findings and directions future research.

Are attention deficit hyperactivity disorder symptoms stable irrespective of recovery from eating disorders? A 1-year follow-up of adult females

OBJECTIVE

To explore the influence of recovery from eating disorders (ED) at 1-year follow-up on self-reported attention deficit hyperactivity disorder (ADHD) symptoms in an unselected group of patients in a specialized ED clinic.

METHODS

Four hundred and eight adult females with an ED were assessed with the World Health Organization adult ADHD Self-Report Scale-Screener, and for comorbid psychiatric symptoms at baseline and 1-year follow-up. Recovery was registered at follow-up.

RESULTS

ADHD symptoms decreased between baseline and follow-up in recovered patients treated for bulimic ED. In not recovered patients, ADHD symptoms were stable. Decreased depressive symptoms were associated to decreased ADHD symptoms at 1-year follow-up.

CONCLUSIONS

Bulimic ED and ADHD are linked together. This link, although not known in every detail, has clinical implications with possible value for bulimic ED patients. Clinical studies exploring implementation of ADHD treatment strategies for Bulimia Nervosa are recommended.

Does ADHD Symptomatology Influence Treatment Outcome and Dropout Risk in Eating Disorders? A longitudinal Study

Attention-deficit/hyperactivity disorder (ADHD) and its symptoms have been shown to be present in patients with eating disorders (EDs) and are associated with increased psychopathology and more dysfunctional personality traits. This study aimed to assess if the presence of ADHD symptoms in patients with EDs affects their short and long-term therapy outcome. A total of 136 consecutively treated ED patients were considered in this study. Baseline pre-treatment evaluation included the Adult ADHD Self-Report Scale (ASRS v1.1) for ADHD symptoms and the assessment of eating symptomatology using the Eating Disorders Inventory (EDI-2). Treatment outcome was evaluated in terms of ED symptoms after cognitive behavioral therapy (CBT) and dropout rate during treatment. Furthermore, we evaluated ED symptoms in treatment completers after a follow-up of 8 years on average. Path analyses assessed the potential mediational role of the EDI-2 total score in the relationship between ADHD and treatment outcome. Results showed that baseline symptoms of ADHD indirectly affected treatment outcome after CBT; the ASRS positive screening was related to higher eating symptomatology (standardized coefficient B = 0.41, p = 0.001, 95% CI: 0.26 to 0.55), and the presence of high ED levels contributed to the increase of dropout (B = 0.15, p = 0.041, 95% CI: 0.03 to 0.33) and a worse treatment outcome (B = 0.18, p = 0.041, 95% CI: 0.01 to 0.35). No direct effect was found between the ASRS positive screening with the risk of dropout (B = -0.08, p = 0.375) and worse treatment outcome (B = -0.07, p = 0.414). These results suggest the relevance of identifying specific treatment approaches for patients with ADHD symptoms and severe eating symptomatology.

Eating Disorders Impact on Vigilance and Decision Making of a Community Sample of Treatment Naive Attention-Deficit/Hyperactivity Disorder Young Adults

Although impulsivity is suggested as a possible link to explain the association of Attention-Deficit/Hyperactivity Disorder (ADHD) with an Eating Disorder (ED), there is little research on how clinical and cognitive/neuropsychological functioning might change when this comorbidity occurs. ADHD individuals are at a higher of developing ED and also obesity. Some research has described the impact of ADHD in clinical treatment-seeking samples of ED patients. Consequently, we investigated how ED impacted on clinical and cognitive variables of a community sample of treatment-naive ADHD individuals. Ninety college students arranged in three groups (ADHD+ED, ADHD only and Controls) were analyzed using semi-structured interviews for ADHD (K-SADS), the Iowa Gambling Task, the Conner's Continuous Performance Test, Digit and Visual span, as well as rating scales for anxiety (STAI), depression (BDI) and impulsivity (BIS-11), and binge eating (BES). We found that ADHD+ED individuals significantly differed from both groups, presenting with a higher body mass index; more hyperactivity-impulsivity symptoms; higher binge eating scores; more omission errors on the Continuous Performance Test; disadvantageous choices on the Iowa Gambling Task. Also, we demonstrated through a moderation/mediation analysis that a greater level of binge eating mediated the increases in body mass index on our sample. There were no significant paths to explain binge-eating severity through changes on any of the neuropsychological tests used. The presence of an ED in normal weight in a community sample of ADHD individuals is associated with higher body mass index and a worse cognitive functioning.