Eat Weight Disord DOI 10.1007/s40519-017-0395-8
ORIGINAL ARTICLE
Attention-deficit/hyperactivity disorder symptoms and psychological comorbidity in eating disorder patients L. Sala1 • G. Martinotti2 • M. L. Carenti3 • L. Romo1 • M. Oumaya1 A. Pham-Scottez1 • F. Rouillon1 • P. Gorwood1 • L. Janiri3
•
Received: 13 January 2017 / Accepted: 23 April 2017 Ó Springer International Publishing Switzerland 2017
Abstract Purpose There is some evidence that eating disorders (ED) and Attention-deficit/hyperactivity disorder (ADHD) share common clinical features and that ADHD might contribute to the severity of eating disorders. A greater understanding of how the presence of comorbid ADHD may affect the psychopathological framework of eating disorder seems of primary importance. The aim of our study was to evaluate rates of ADHD in three ED subgroups of inpatients: anorexia nervosa restricting type (AN-R), anorexia nervosa binge-eating/purging type (AN-BP) and bulimia nervosa (BN). The secondary aim was the evaluation of the associated psychological characteristics. Method The sample consisted of 73 females inpatients (mean age 28.07 ± 7.30), all with longstanding histories of eating disorder (ED). The presence of a diagnosis of ADHD was evaluated in a clinical interview based on DSM-IV-TR criteria. The following psychometric instruments were used: the eating attitude test (EAT-40), the Bulimic Investigatory Test, Edinburgh (BITE), the Eating Disorder Inventory (EDI-2), the Wender Utah Rating Scale (WURS), the Brown Attention Deficit Disorder Scale (BADDS), the Hamilton scales for Anxiety (HAM-A) and
& L. Sala
[email protected] 1
Clinic of Mental Illnesses and Brain Disorders, Sainte-Anne Hospital, University Paris V Rene´ Descartes, 100 rue de la Sante´, 75674 Paris Cedex 14, France
2
Department of Neuroscience and Imaging, ‘Gabriele d’Annunzio’ University, Chieti, Italy
3
Institute of Psychiatry and Psychology, Catholic University, Rome, Italy
Depression (HAM-D), and the Barrat Impulsivity Scale (BIS-10). Results Among the three ED subgroups, 13 patients reported comorbidity with ADHD; three in the AN-R subtype, nine in the AN-BP and one in the BN. The remaining 60 patients (n = 34 AN-R; n = 19 AN-BP; n = 7 BN) presented only a diagnosis of ED. The EAT (p = 0.04) and HAM-A (p = 0.02) mean scores were significantly higher in patients with comorbid ADHD. Conclusions In our study the comorbidity between ADHD and ED appeared to be frequent, particularly among patients with AN-BP. ED inpatients with higher level of anxiety and more abnormal eating attitudes and bulimic symptoms should be assessed for potentially associated ADHD. Keywords Anorexia nervosa Bulimia nervosa Eating disorders Attention-deficit/hyperactivity disorder
Introduction Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that is estimated to affect between 5 and 10% of school-aged children [1] and 2.5% of adults [2–4]. Affected patients have difficulties focussing and sustaining attention, modulating activity level and controlling impulses and emotions. The new diagnostic and statistical manual of mental disorders (DSM-5), consistent with the previous DSM-IV-TR, distinguishes three subtypes of the disorder: one with predominance of inattentiveness (ADHD-I), another with a predominance of hyperactivity and impulsivity (ADHD-HI) and a third type that combines the other two (ADHD-C) [5].
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ADHD in childhood as well as adulthood is highly comorbid: it is well-documented that individuals with ADHD experience a wide range of psychiatric comorbidities including mood disorders, anxiety disorders and addictive disorders [6–8]. On the contrary, the comorbidity with eating disorders (ED) has not been studied in details [9]. Additionally, the existing research utilised a very limited number of specific diagnostic categories. There are only a few studies addressing this issue and most of them with small samples and different methodologies [10, 11]. There is some evidence that ED and ADHD might share common clinical features and that ADHD rates may be increased in ED [12] and/or contribute to the severity of eating pathological behaviours. The presence of comorbid ADHD in ED patients may affect the course of illness and thus may be clinically highly relevant for the treatment of ED; however, data from the literature appear to be controversial, probably due to the heterogeneity of both the syndromes. Although the link between AN and ADHD is still controversial, some studies suggest an association between the two [11]. Brewerton and Duncan’s study [13] found a positive association between ADHD and ED, especially for women with ADHD and lifetime prevalence of anorexia nervosa. To compare psychiatric comorbidity between the three subtypes of ADHD in adults, Sprafkin and colleagues [14] found that the ADHD:HI group ratings were more severe than those of the ADHD:I group for symptoms of eating disorders, particularly with respect to symptoms of Anorexia. Wentz et al. [15] found an ADHD prevalence rate of 10–17% in a group of Anorexia nervosa (AN) purging type ED patients. Stulz et al. [16] found that most correlations between the severity of ADHD features and the severity of ED symptoms were low (r \ 0.30) and did not reach statistical significance. This study was composed of 32 women: 12 with AN, 6 with BN, and 14 with EDNOS. The results suggested that ED with ADHD exhibited higher binge-purging features, such as low selfesteem, impulsive traits [9, 17, 18] and neurobiological dysfunctions [19]. Impulsiveness is a common feature of ADHD and evidence in literature suggests that impulsivity traits may be an indicator of poor prognosis for individuals with bulimia nervosa (BN) [20, 21]. Fernandez-Aranda et al. [11] found that ADHD symptom levels were similar in bulimia, eating disorder not otherwise specified and binge eating subtypes, and lower in patients with anorexia nervosa. A path model showed that ADHD was associated with high novelty-seeking and low self-directedness, whereas ED severity was influenced by ADHD severity and low self-directedness. Bingeing/purging ED subtypes have a high ADHD symptoms level and high psychopathology. The authors found that higher
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ADHD symptom scores were correlated with higher eating disorder inventory (EDI-2) total score and EDI-2 interoceptive awareness score. A negative association appeared between the EDI-2 perfectionism score and the ADHD symptoms scale score. Considering the AN sample, a positive association was found between the EDI-2 total score and the ADHD scale score. Biederman et al. [22] found that the patients with ADHD had an elevate risk of develop eating disorders, especially BN: ADHD patients were 3.6 times more likely to meet criteria for an ED and, particularly, were 5.6 times more likely to meet criteria for bulimia nervosa compare to controls; the authors of this study underlined how this comorbidity increase the risk of additional morbidity and dysfunction. Nazar et al. [23] found that obese ADHD patients showed a larger number of psychiatric comorbidities especially Substance Abuse Disorders, and higher scores on psychopathology rating scales like the SCL-90. The highest prediction for binge eating in the regression model was the presence of depressive symptoms, followed by ADHD inattention symptoms and trait-impulsivity, and depressive symptoms can predict the presence of binge eating in obese patients. On the contrary, in 2006, Blinder et al. study [24] highlighted how the patients with eating disorders showed an extremely high comorbidity, but, the prevalence of ADHD in eating disorders was low enough to preclude a statistical significance. A greater understanding of how the presence of comorbid ADHD may affect the psychopathological framework of eating disorder seems of primary importance. To provide more clarity and to increase current knowledge on the current connexion between these two disorders, the aim of our study was to evaluate and identify the rates of ADHD in the three main typologies of ED, namely anorexia nervosa restrictive type (AN-R), anorexia nervosa binge-purging (AN-BP), and bulimia nervosa (BN). The secondary aim was to evaluate the differences between ED subjects with and without an ADHD diagnosis in terms of severity and associated psychopathology, because we consider that this difference may be clinically useful in term of therapeutic implications for ED.
Materials and methods Participants Seventy-five female inpatients, aged 17–50 years old, with ED and hospitalised in a specialised ED ward of a university hospital located in Paris (France), were enrolled over a 12 month period. Seventy-three patients were evaluated in a clinical interview with a senior psychiatrist to classify their ED based on DSM-IV-TR criteria. Subjects
Eat Weight Disord
were divided into: anorexia nervosa-restrictive type, anorexia nervosa-binge/purge type and bulimia nervosa (APA). Anorexia nervosa is characterized by distorted body image and excessive dieting, bulimia nervosa, instead, is characterized by recurrent binge eating episodes followed by selfinduced vomiting or other compensatory behaviour. Two patients refused to participate. The research protocol was approved by the Ethics Committees of the hospital and the Ethical Group of the University (UFR SPSE). Each patient received a letter from the Head of the Psychiatry Department that confirmed the researchers involved, the objectives of the study, the clinical protocol, and data anonymity prior to the signature of an informed consent form that confirmed his/her participation. Subjects received no form of payment for participating in the research. Clinical assessments The presence of a diagnosis of ADHD was evaluated in a clinical interview based on DSM-IV-TR criteria. This diagnosis was integrated by a retrospective instrument, the Wender Utah Rating Scale (WURS) [25]; this scale was designed to help assess adult’s descriptions of their childhood behavior. The Brown Attention Deficit Disorder Scale (BADDS) [26] was also administered to assess persisting ADHD symptoms in adulthood. Symptoms severity of ED was evaluated by the validated French versions of the eating attitude test (EAT-40) [27], the Bulimic Investigatory Test, Edinburgh (BITE) [28], the eating disorder inventory (EDI-2) [29]. The Hamilton Rating Scales for Anxiety (HAM-A) [30] and Depression (HAM-D) [31], and the Barratt Impulsivity Scale (BIS-10) [32] were also administered. These scales were hand-delivered to patients and collected upon completion. We measured patients’ weight and height to determine their body mass index (BMI = weight/height2). Statistical analysis Where statistical comparisons between AN-R, AN-BP and BN groups are reported, oneway ANOVAs were performed using reported means and standard deviations. The test for homogeneity of variances was confirmed using the Levene statistic. The significance level was set at 0.05. All analyses were performed with the PASW Statistics18 software.
Results The sample consists of 73 females inpatients (mean age 28.07 ± 7.30), all with longstanding history of ED, 37 patients having AN-R, 28 with AN-BP and 8 with BN.
Among the three ED patient subgroups, irrespective of the presence or the absence of ADHD comorbidity, one-way ANOVA of age, gender, age of start of disorders, age of first consultation for ED, number and duration of hospitalisations revealed no significant differences (Table 1). Conversely, the BMI differed significantly within the three ED subgroups (p \ 0.01), with BN subtypes showing higher scores. The mean number of hospitalisations differed significantly among the three ED subgroup (p = 0.05), but only in those subject with concurrent ADHD. In relation to the number of suicide attempts, a statistically significant difference (p = 0.01) was observed among the two subpopulations of anorexic patients (AN-R vs AN-BP) with a higher mean number of attempted suicides in the AN-BP subgroup with respect to AN-R. The mean number of suicide attempts in the BN subtype did not differ significantly from those with AN. The total mean BIS scores were significantly different (p \ 0.01) within the three ED subgroups; this difference was particularly prominent among the anorexic subtypes (AN-R: 43.89 ± 11.97 vs AN-BP: 55.21 ± 14.99) (p \ 0.01). In terms of anxiety and depression, no significant differences were found for results between the three ED subgroups. Taking into account the abnormal eating attitudes and behaviours, statistically significant differences were found. Results from EAT and EDI-2 revealed higher scores in AN-BP patients with respect to AN-R subgroups. The assessment of bulimic symptoms also showed significant differences (p \ 0.01) among the three ED subgroups: AN-BP showed higher mean scores for BITESymptoms with respect to AN-R and BN subgroups. In terms of bulimic severity the BN subgroup differed significantly (p \ 0.0001) with respect to the others ED subgroups. However, specifically, one-way ANOVA revealed that in ED patients without ADHD, significant differences in terms of BITE-Severity (p \ 0.0001), were observed, once again, only among the anorexic subgroups. Eating disorders and ADHD symptoms Among the three ED subgroups, 13 patients reported comorbidity with ADHD as to DSM-IV: three in the AN-R subtype, 9 in the AN-BP and 1 in the BN. The remaining 60 patients (n = 34 AN-R; n = 19 AN-BP; n = 7 BN) presented only a diagnosis for ED. Considering the differences between patients with and without ADHD comorbidity, no significant differences was observed in term of BMI (p = 0.05) or impulsivity (p = 0.18). Anxiety differed significantly between patients with ADHD and those with non-ADHD, with ADHD patients showing higher scores (p = 0.02).
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Eat Weight Disord Table 1 Clinical characteristics of three groups of inpatients with different eating disorders: mean (SD) and one-way ANOVA Sample
Anorexic patients (AN) Restricting (R) n = 37
Gender (female)
Binge-purging (BP) n = 28
Bulimic patients (BN)
Total
F
n=8
N = 73
df
p
1.97 (0.16)
2.00 (0.00)
2.00 (0.00)
1.99 (0.12)
0.479
2.70
0.62
Age
27.62 (7.22)
28.25 (6.97)
29.50 (9.44)
28.07 (7.30)
0.227
2.70
0.80
Age of start of disorders
18.14 (5.24)
16.68 (4.82)
16.86 (3.13)
17.43 (4.90)
0.742
2.67
0.48
Age of 1st consultation
21.17 (6.04)
20.96 (6.06)
21. 86 (6.41)
21.16 (6.00)
0.060
2.67
0.94
2.57 (3.30)
2.43 (2.91)
3.71 (3.95)
2.63 (3.19)
0.459
2.67
0.63
287.88 (412.22)
139.71 (203.57)
116.17 (158.76)
210.58 (327.38)
1.874
2.64
0.16 0.01
Number of hospitalizations Total duration of hospitalizations (days) Number of suicide attempts
0.23 (0.55)
1.68 (2.79)
1.98 (0.75)
0.91 (2.00)
4.643
2.67
14.16 (2.09)
16.42 (2.40)
18.59 (3.36)
15.51 (2.79)
1.888
2.70 \0.001
WURS Total ADD
21.68 (16.31) 42.92 (24.29)
39.21 (18.12) 58.96 (23.29)
36.88 (25.08) 53.00 (23.02)
30.07 (19.78) 50.18 (24.66)
8.150 3.690
2.70 2.70
0.001 0.03
BIS total
43.89 (11.97)
55.21 (14.99)
51.38 (12.76)
49.05 (14.17)
5.919
2.70
0.004
HAM-A
10.54 (5.17)
12.82 (4.29)
9.38 (3.93)
11.29 (4.83)
2.589
2.70
0.08
HAM-D
8.08 (4.75)
6.50 (4.81)
10.21 (4.43)
8.73 (4.75)
2.721
2.70
0.07
BMI Instruments
EAT
47.54 (25.66)
66.5 (19.87)
55.13 (21.76)
55.66 (24.56)
5.344
2.70
0.007
EDI total
78.84 (51.27)
121.36 (45.04)
91.63 (34.92)
96.55 (50.96)
6.433
2.70
0.003
BITE symptom
10.49 (5.71)
23.68 (2.55)
2.25 (8.84)
16.84 (8.28)
55.982
2.70 \0.001
BITE severity
2.86 (4.78)
10.89 (5.52)
11.50 (5.61)
6.89 (6.54)
22.860
2.70 \0.001
Regarding the results from ED symptoms assessment scales, univariate ANOVA have highlighted statistically significant differences. Mean EAT scores were significantly higher in ADHD patients vs non-ADHD (p = 0.04). Similarly we had significantly higher in ADHD patients vs non-ADHD for the EDI (p = 0.02) and BITE-Symptom (p = 0.04) scores. Results from the BITE-Severity showed no significant differences between ADHD and non-ADHD patients (p = 0.31). Regardless the division into ADHD and non-ADHD subjects as to DSM-IV, the mean WURS scores were higher in AN-BP with respect to the AN-R subgroup (p \ 0.01) (Table 2). The mean BADD scores also showed
significant differences (p = 0.03) among the two anorexic patients’ subtypes, with higher scores in the AN-BP subgroup.
Discussion In the present study we explored the rates of ADHD in three ED subgroups, showing that its highest frequency was observed in the AN-BP subtype. Moreover, we evaluated the association among ADHD and ED symptomatology and the associated psychological comorbidity.
Table 2 Specificities of eating disorder according to presence (versus absence) of ADHD comorbidity: mean (SD) and One-way ANOVA With ADHD
Number of hospitalizations
Anorexic patients (AN)
Bulimic patients (BN)
Total
Restricting (R) n=3
Binge-purging (BP) n=9
n=1
n = 13
3.00 (1.73)
1.78 (2.22)
8.00
2.54 (2.60)
Without ADHD
n = 34
n = 19
n=7
n = 60
BITE severity
2.50 (3.94)
11.84 (5.96)
10.86 (5.73)
6,43 (6,60)
123
25.733
F
df
p
3.916
2.10
0.05
2.57
\0.001
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We recruited patients with chronic ED according to DSM-IV-TR criteria [33] and we classified their ED into the three subgroups: AN-R, AN-BP and BN. The attendance of ADHD was diagnosed as to DSM-IV criteria, and it was detected, also, integrating the assessment with the WURS, which has been reported to identify 96% of adults with ADHD (96% sensitivity) and 96% of normal subjects (96% specificity) [25] and with the ADD [26]. Reviews of relevant literature appear to support a relationship between ADHD and ED [9, 34], although some controversial reports are not consistent [24]. The frequency of ADHD in different ED samples varying between 1 and 12% (9), whereas our study supports a high comorbidity between the two disorders, consistently with another pilot study [15], namely 18% (n = 13). In our sample ADHD rates differed among the three ED subtypes, as previously described in another study [11], where the most impulsive groups, such as BN, BED and EDNOS subtype, presented a higher level of ADHD symptoms with respect to the AN group. The authors provide a possible explanation of these results and suggest that the BED subtype might share a common feature with the ADHD population, namely reduced impulse control. Most of the ADHD cases identified in our study occurred in the AN-BP subtype, both in childhood and adulthood, similarly reported by Yates et al. [10]. This finding is also consistent with that of Wentz et al. showing a high prevalence rate of ADHD in AN-BP patients, suggesting that the problem of loss of control, in the case of AN-BP with ADHD, could possibly be explained by the underlying ADHD with childhood onset [15]. Our patients with comorbid ADHD, showed greater severity levels of symptoms related to ED and other studies, evaluating the presence of eating pathologies in ADHD and non-ADHD youth, reported that those with ADHD were more likely to engage in pathological eating behaviours [20, 21]. In terms of the severity of bulimic symptoms, namely frequency of binging and purging behaviours, our study revealed no statistical differences patients with ED and with versus without ADHD. In our small sample the BN patients reported greater scores, compared to the other ED subtypes; however, it is interesting to underline that this difference, specifically, did not persist in patients without ADHD where the AN-BP patients appeared to be significantly more severe. These results could support recent evidence in the literature which suggests that subjects with ADHD have a higher likelihood of BN-related symptoms than those without ADHD, probably because BN has common clinical features with ADHD, such as impulsivity [10, 12, 15, 20–22, 35, 36]. Seitz et al. study [37] found that patients with BN and childhood ADHD were even more impulsive than those with BN alone, as measured by the total BIS score; the
authors suggest that there is an additive effect with regard to impulsivity The occurrence of depression and anxiety could cause more emotional stress, which would worsen both ADHD and BN symptoms. The present study also provides interesting findings in term of impulsivity. The ED patients with comorbid ADHD showed no significant differences compared to those without ADHD. However, within the three ED subgroups, the AN-BP subtype was more impulsive compared to the others ED subgroups, both with and without ADHD. It was proposed that impulsivity could contribute to the link between ADHD and BN [37, 38]; impulsive behaviours in AN-BP patients, in terms of loss of control, bingeing and purging, similarly to those of BN patients, could explain our findings about impulsivity, at least for patients with ADHD comorbidity. With regard to the dimensions of depression and anxiety, frequently impaired in ED, evidence from literature matches our findings. As revealed in a preliminary study [22], our ED patients with comorbid ADHD reported more symptoms of anxiety compared to those without ADHD. On the contrary, the finding of the present study is not consistent with the study of Biederman and colleagues [22] in relation to depressive symptoms. Our study has some limitations, namely the relatively small sample size. Other limitations include the absence of a control group for another addictive behaviour and the use of self-administers tests without a structured interview. However, this is only a pilot study and these preliminary and promising findings need to be confirmed by further studies of larger samples.
Conclusion In conclusion, the present study, underscores that the rates of ADHD differ among the three ED patient subtypes, these differences may already be present in childhood. It is possible that the core symptoms of ADHD give rise to pathological eating patterns and this seems to be especially prominent regarding ADHD impulsiveness. In our small sample, the relationship between ADHD and ED seems to appear particularly among ED patients who exhibit binge-purging features and characteristics. Moreover, in this study, the co-occurrence of ADHD appears to increase the psychiatric comorbidities associated with ED, specifically in terms of anxiety. However, there is a lack of studies on ADHD and ED and the link between these two disorders is still unclear. More research is needed to elucidate the nature of the relationship between ADHD and ED, as well as to evaluate this comorbidity, to better understand clinical and therapeutic implications.
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The high comorbidity between BN and ADHD, as well as the associated higher burden for patients with this comorbid condition, we would prescribe that clinicians should screen BN patients for ADHD.
11.
Compliance with ethical standards Conflict of interest The authors declare that they have no conflicts of interest.
12.
Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
13.
14.
Informed consent Informed consent was obtained from all individual participants included in the study. 15.
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