Bulimia nervosa patient diagnosed with previously unsuspected ADHD in adulthood: Clinical case report, literature review, and diagnostic challenges

Abstract

There is increasing literature suggesting a link between attention-deficit hyperactivity disorder (ADHD) and eating disorders (EDs), especially bulimia nervosa. ADHD is under-diagnosed in girls and children of high intelligence are typically missed. We identified a case of a 23-year-old woman suffering from severe bulimia nervosa and previously unsuspected ADHD in adulthood; we diagnosed and treated her with extended-release methylphenidate. We performed a literature review on the ADHD and bulimia nervosa comorbidity. We discuss the reasons why her ADHD remained undiagnosed and the difficulties in diagnosing ADHD in patients with EDs. We suggest that identifying comorbid ADHD is crucial for these patients and argue for the use of a structured interview, collateral history and investigation of onset of symptoms to establish a diagnosis of ADHD in adults with bulimia nervosa. Comorbidities and overlap of symptomatology need to be taken into account.

Preliminary Evidence for the Off-Label Treatment of Bulimia Nervosa With Psychostimulants: Six Case Reports

“…These 6 cases are consistent with findings of psychostimulant use in binge eating disorder patients and bulimia nervosa patients with comorbid ADD/ADHD . In particular, the results provide additional evidence that safety can be maintained in a carefully selected and monitored bulimia nervosa population that is being treated with psychostimulants.…”

“…Furthermore, case reports of this comorbid population (bulimia nervosa and ADHD) have noted incidental improvements in binge/purge behaviors after psychostimulants were initiated for ADHD. A review of the 17 available cases revealed that when treated with a psychostimulant, 10 patients demonstrated full remission of bulimia nervosa symptoms, 6 patients demonstrated improvement, and only 1 patient relapsed after weight loss and subsequent noncompliance . In bulimia nervosa patients without ADHD, there have only been 2 cases described, both of which noted decreases in binge/purge behaviors after the initiation of psychostimulants …”

“…Although there are valid grounds for this concern, there are no rigorous data to confirm whether these potential complications should be grounds for an absolute contraindication, or rather, a factor that needs to be carefully monitored in high‐risk bulimia nervosa subpopulations. Nevertheless, the available published case‐based evidence from comorbid ADHD/bulimia nervosa populations would suggest that problematic weight loss may be the exception rather than the rule, especially under careful supervision and monitoring …”

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

“…Stimulants commonly used to treat ADHD strengthens the attention capacity, thus facilitating active participation in the treatment process. Additionally, stimulants used to treat ADHD are reported to dramatically reduce concomitant BN symptoms in a number of case reports (Drimmer, ; Dukarm, ; Ersson, Klanger, Wallsten, Nilsson, & Lindstrom, ; Guerdjikova & McElroy, ; Ioannidis, Serfontein, & Muller, ; Keshen & Ivanova, ; Schweickert, Strober, & Moskowitz, ). Likewise, stimulants are shown to reduce ED symptoms in BN without established ADHD in a number of case reports (Keshen & Helson, ; Messner, ; Sokol, Gray, Goldstein, & Kaye, ) and in a small randomized controlled trial (Ong, Checkley, & Russell, ).…”

Dietary-induced binge eating increases prefrontal cortex neural activation to restraint stress and increases binge food consumption following chronic guanfacine

“…These findings, however, have been limited to case studies (Ioannidis et al, 2014;Keshen and Ivanova, 2013) or small clinical populations (McElroy et al, 2007). One reason for the effectiveness of these medications is that ADHD is comorbid with BN and BED.…”