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Brazilian Journal of Psychiatry

Print version ISSN 1516-4446On-line version ISSN 1809-452X

Rev. Bras. Psiquiatr. vol.26 no.4 São Paulo Dec. 2004 



Comorbid eating disorders in a Brazilian Attention-Deficit/Hyperactivity Disorder adult clinical sample



Paulo MattosI; Eloisa SaboyaI; Vanessa AyrãoI,II; Daniel SegenreichI; Monica DuchesneI,III; Gabriel CoutinhoI

IStudy Group on Attention Disorder, Institute of Psychiatry of the Federal University of Rio de Janeiro
IIInstitute of Mental Health Studies - Federal University of Rio de Janeiro
IIIGroup on Obesity Disorders and Eating Disorders, State Institute on Diabetes and Endocrinology





Although comorbidity between attention-deficit/hyperactivity disorder (ADHD) and eating disorders (ED) is relevant for clinical treatment, it is seldom investigated.
METHODS: 86 DSM-IV attention deficity hyperactivity disorder patients out of 107 self-referred adults in a specialized center for attention deficity hyperactivity disorder were interviewed using SCID-R to evaluate the lifetime prevalence of ED and other comorbid conditions.
RESULTS: Nine attention deficity hyperactivity disorder patients had comorbid eating disorders; binge eating disorder (BED) was the most common diagnosis. The group with eating disorders presented a higher prevalence of other comorbid disorders (p=0.02). No significant differences were found on gender, age at assessment, schooling level and type of attention deficity hyperactivity disorder between groups.
CONCLUSION: Attention deficity hyperactivity disorder clinical samples may have a high prevalence of BED comorbidity. Patients with attention deficity hyperactivity disorder and eating disorders may have a different comorbid profile.

Keywords: Attention deficit disorder with hyperactivity; Eating disorders; Bulimia; Comorbidity.




Attention Deficit/Hyperactivity Disorder (ADHD) has a high comorbidity rate1 with a number of conditions. Two studies addressing ADHD comorbidity in children and adolescents in Brazil2-3 revealed a high and similar prevalence of comorbidity.

There are some case reports of ADHD in Eating Disorders (ED) patients4-5 and the not yet published National Comorbidity Survey Replication6 recently revealed a high prevalence rate of Bulimia Nervosa (BN) in adult ADHD.

Some authors7-8 have suggested that binge eating is better understood as a general disregulation of impulse control. BN and Anorexia Nervosa (AN) have also been conceptualized in terms of impaired attention9 and impulsivity,10-11 and disexecutive symptomatology is seen both in ADHD and BN.10-11 Patients with a higher degree of impulsivity or inattention to inner sensations (like those with ADHD) possibly have more binge behavior.14

This comorbidity is of clinical interest since some case reports point to a better efficacy when a stimulant is administrated5-7 but there is also a potential harm in prescribing stimulants in ED6 mainly because of their anorexic properties.



To determine 1) the prevalence of ED in an adult DSM-IV ADHD clinical sample; 2) if the group of ADHD patients with comorbid ED is different from the one without this comorbidity regarding age at assessment, educational level, gender, ADHD type and number of other comorbidities.



107 consecutive adults (48 men, 59 women) aged 18 to 52 enlisted for treatment at the Institute of Psychiatry of the Federal University of Rio de Janeiro were initially screened at a baseline clinical interview and further interviewed with SCID-R by trained psychiatrists and psychologists; only 8 were not self-referred. Past ADHD symptoms were investigated either trough the patients own recollections or parent's report, using the ADHD Childhood Symptoms Scale.15 Body Mass Index (BMI) was calculated and patients with DSM-IV ADHD diagnosis were enrolled for further treatment. All patients were pharmacological treatment-naive for ADHD.

The group with ADHD and ED (ADHD-ED) was compared to the group with ADHD without ED (ADHD) using Student t test (age at assessment, educational level), and Fisher Exact Test (gender, ADHD type and number of other comorbidities).



Only 86 (80.3%) of screened individuals fulfilled DSM-IV criteria for ADHD, Adult Type. Of this ADHD sample, nine patients (10.4%) had an ED diagnosis (Table 1) which was confirmed in the follow-up treatment period, present BED being the most common one (7 cases). Although women were twice more common in the ADHD-ED group, this difference did not reach statistical significance (p=0.3).



Mood, Anxiety and Alcohol and Drug Abuse and Dependency Disorders were seen in comorbidity in the ADHD-ED group (Table 1), but also in the ADHD group. No patient in the ADHD-ED group had a BMI below 20; one patient in this group had BMI above 25 but below 30.

Although the ADHD-ED group had less years of education and was younger, these differences again did not reach statistical significance (respectively, p=0.34 and p=0.24). The only significant difference between the groups was on the comorbid profile as ADHD-ED has a significantly higher rate of cases with at least one comorbid condition (p=0.02) than ADHD without ED (Table 2).




The 8.13% prevalence of BED comorbidity found in this sample should be considered unexpected since the prevalence of ED in the general population is low: BED is the most prevalent ED and is estimated around 2.6%.16 The comorbidity was not suspected during the initial clinical interview and was only disclosed during the SCID-R, a feature commonly seen when ED is not the main diagnosis or reason for referral.

Since only two DSM-IV criteria for BED involve impulsivity or its correlates17 (a sense of lack of control over food ingestion (A2) and eating more quickly than normal (B1), ADHD impulsivity per se would not be enough for an ED diagnosis, suggesting a true comorbidity. A clinical aspect was however considered atypical in those BED cases: only two of them were overweight and none of them was obese. Although weight is not part of BED criteria, this is a very common feature.

As expected, women outnumbered men in the ADHD-ED group, since women are overrepresented in all ED. Our study may have not had enough power to detect a significant difference between groups due to the small sample of patients with ADHD-ED. Less education is not generally seen in ED samples, at least clinical ones.19 ED patients usually portray a large number of comorbidities and the same holds true for ADHD patients. However, in the ADHD-ED group, the number of comorbidities was higher than in the ADHD group, suggesting a possible additive effect.



The results prompt further analyses of larger series and possibly different socio-cultural contexts to confirm these preliminary findings. Comorbidity of ADHD with BED might require specific therapeutic approaches, since the use of psychostimulants (the first-line agents) may jeopardize the treatment of an ED because of the anorexic properties of those drugs. On the other side, BED patients with ADHD may need specific treatment for their impulsivity in order to properly gain control over binge episodes. Inattention to satiety cues might also be an important factor in the development and also treatment of bulimia. Also, a number of different pharmacologic treatments have already been proposed in BED18 and their use should be taken into account in ADHD patients with this comorbidity.



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Correspondence to
Paulo Mattos
Rua Paulo Barreto, 91
22280-010 Rio de Janeiro, RJ, Brasil

Conflict of interests: Dr Mattos is on the advisory board of, is a speaker for, or has received funding from Pfizer, Janssen-Cilag, Eli Lilly, Wyeth, Novartis, and GlaxoSmithKline.
Received in 06.04.2004
Accepted in 09.22.2004



Original version accepted in English

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