ADHD, Binge Eating Disorder and Borderline Personality Disorder: History
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Contributor:
Derek Ryan
,
Joseph Sadek

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by impulsiveness, inattention, restlessness, and hyperactivity. This classification is provided because onset occurs in early childhood before age 12 and is characterized by developmental deficits inconsistent with or excessive for developmental level or age.

  • attention deficit hyperactivity disorder
  • ADHD
  • borderline personality disorder
  • BPD
  • binge eating disorder
  • BED
  • impulsivity
  • psychosocial risk factors

1. Attention Deficit Hyperactivity Disorder (ADHD)

Attention deficit hyperactivity disorder (ADHD) has a global prevalence rate of 5% in school children and 2.5% in adults, with the diagnosis being more prevalent in males [1]. Cultural and gender-related diagnostic issues have been identified as possible contributing factors to the heterogeneity in ADHD prevalence rates within populations and between regions [2]. For example, there are lower ADHD diagnostic rates within Latino and African American populations in the United States that may be related to cultural differences in informant symptom ratings [2]. Additionally, it has been found that inattentive ADHD presentation is more common in females than males, which may have contributed to historically lower rates of ADHD identification in females by clinicians [2]. As there are no biological tests to diagnose ADHD, varied clinical assessment methodologies may also give rise to these differences [3].
Three subtype specifications of ADHD have been previously identified: hyperactive-impulsive type, inattentive-distractible type, and combined type [4]. However, this terminology has been modified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which deemphasizes ADHD subtypes by classifying them as presentations [5]. This change agrees with current research demonstrating that ADHD symptoms are dynamic and susceptible to change across the lifespan as opposed to static qualities [5]. Thus, an individual’s ADHD presentation demonstrates current symptomology. A minimum of five symptoms in adults and six in children and adolescents of the DSM-5-specified symptoms for a given ADHD presentation must have been persistent over the past six months to meet the criteria [2]. Apart from these, diagnostic specifications for disease severity are included, ranging from mild to severe.
Inattention refers to lacking the ability to stay on task, listen when spoken to, organize tasks, or engage in mentally strenuous activities in addition to high distractibility and forgetfulness [2]. Hyperactivity pertains to excessive or inappropriate motor movement such as fidgeting, running, talking, interrupting, and waiting. In adulthood, this can manifest as inner restlessness [4]. Relevant to this research, impulsivity refers to behaving or acting in the moment without consideration, typically in an inappropriate or risky manner [5]. Although a level of impulsiveness is to be expected in normal individuals, when it begins to impact daily functioning (e.g., social or occupational), it crosses a threshold, becoming pathological. An example of this would be failing to assess long-term consequences while making decisions, demonstrating a desire for instant gratification [2]. All three ADHD presentations are common; however, hyperactive and impulsive symptoms typically diminish with age [5].
The interactions of many genetic and environmental risk factors are involved in the etiology of ADHD [3]. It is a complex disease that is multifactorial and strongly inherited within families. Exposure to non-genetic factors in the womb (prenatal), during birth (perinatal), and throughout childhood (psychosocial) have been associated with ADHD development. Moreover, the presence of comorbidities in clinical settings are numerous in individuals diagnosed with ADHD [2]. Notably, there is a regular intersection between childhood ADHD and “externalizing disorders” such as oppositional defiant disorder [3]. Additional neurocognitive, anxiety, personality, substance use, and eating disorders may exist.

2. Binge Eating Disorder (BED)

Binge eating disorder (BED) is an eating disorder characterized by recurrent food binges, with excessive caloric consumption and loss of control without subsequent compensatory behaviours [2]. Examples of these habits include self-induced vomiting, extreme exercise, and fasting [6][7]. It is the third main category of eating disorders listed in the DSM-5 and was previously classified as an eating disorder not otherwise specified (EDNOS) in the DSM-4. An episode of binge eating is defined as a larger-than-normal quantity of food being consumed in a discrete period during which one feels unable to keep from or stop eating [2]. Onset typically occurs later in adult life, and individuals with BED have comorbid psychological illness and obesity [8].
To be diagnosed, this behaviour must have occurred at least once per week for three months, with BED severity ranging from mild to severe, depending on the frequency of episodes per week. Additionally, individuals must have marked distress regarding the episodes, plus three of the following symptoms: eating when not physically hungry, eating more rapidly than usual, feeling guilty after eating, and preferring to eat alone or eat when not physically hungry. The global prevalence of BED is 0.9%, with the diagnosis being more prevalent in females. However, the gender ratio is more balanced in BED than in bulimia nervosa [2].
Similar to ADHD, BED’s etiology is thought to result from complex interactions between multiple genetic and non-genetic factors [7]. Emerging research has implicated neurobiological impairments in the development of the disease, specifically focusing on the emotional regulatory, inhibitory control, and reward processing domains. Hence, impulsivity has been proposed as one of the central risk factors for BED [6].

3. Borderline Personality Disorder (BPD)

Borderline personality disorder (BPD) is a cluster B personality disorder characterized by an intense fear of abandonment, recurring suicidal thoughts or self-harm, paranoid ideation or dissociation, identity difficulties, chronic feelings of emptiness, impulsive behaviour, and unstable moods and relationships [4]. The point prevalence of BPD is estimated at 1% in community settings, increasing to 22% in outpatient clinical settings [9]. Around 75% of patients diagnosed with BPD are female [2]. As outlined by the DSM-5, for a diagnosis of BPD, patients must have a chronic pattern of functional impairment in addition to five of nine listed DSM-5 criteria, including risky behaviours, fear of abandonment, intense mood swings, and patterned unstable relationships [2][4]. Notably, binge eating is one of the impulsiveness criterion parts of the BPD symptom profile. If all criteria are met for both disorders, both diagnoses are given.

4. Rationale

ADHD research is critical because of its prevalence, persistence into adulthood, and adverse outcomes extending beyond the affected individual [3]. Prior studies have demonstrated associations between ADHD and BED [10][11][12][13][14], ADHD and BPD [15][16], as well as BED and BPD [17][18]. In the literature, impulsivity has been proposed as being associated with BPD and BED [18]. In ADHD diagnoses, there is also a significant impulsivity factor [19], thus suggesting a possible underlying link between the three psychiatric disorders. However, such connections have not yet been thoroughly tested or fully understood [6]. It has been suggested for future research to investigate in a clinical sample the relationship between ADHD and BED concerning impulsivity. Nazar et al. also proposed that future research should investigate the prognosis and course of eating disorders comorbid with ADHD compared to either diagnosis alone [20]. This research has the potential to provide valuable insight into and develop the clinical profile of ADHD patients with BED and BPD as a distinct subgroup. This is a critical area to explore because this information will help to inform on currently unclear areas of ADHD, BED, and BPD treatment as well as address and identify potential risk factors for the comorbid disorders.

This entry is adapted from the peer-reviewed paper 10.3390/brainsci13040669

References

  1. Song, P.; Zha, M.; Yang, Q.; Zhang, Y.; Li, X.; Rudan, I. The prevalence of adult attention-deficit hyperactivity disorder: A global systematic review and meta-analysis. J. Glob. Health 2021, 11, 04009.
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed.; American Psychiatric Association: Washington, DC, USA, 2013.
  3. Thapar, A.; Cooper, M. Attention deficit hyperactivity disorder. Lancet 2016, 387, 1240–1250.
  4. Sadek, J. A Clinician’s Guide to Adhd; Springer International Publishing: Cham, Switzerland, 2017.
  5. Epstein, J.N.; Loren, R.E. Changes in the Definition of ADHD in DSM-5: Subtle but Important. Neuropsychiatry 2013, 3, 455–458.
  6. Steadman, K.M.; Knouse, L.E. Is the Relationship Between ADHD Symptoms and Binge Eating Mediated by Impulsivity? J. Atten. Disord. 2016, 20, 907–912.
  7. Giel, K.E.; Bulik, C.M.; Fernandez-Aranda, F.; Hay, P.; Keski-Rahkonen, A.; Schag, K.; Schmidt, U.; Zipfel, S. Binge eating disorder. Nat. Rev. Dis. Prim. 2022, 8, 16. Available online: https://doi-org.ezproxy.library.dal.ca/10.1038/s41572-022-00344-y (accessed on 16 October 2022).
  8. Kornstein, S.; Kunovac, J.; Herman, B.; Culpepper, L. Recognizing binge-eating disorder in the clinical setting: A review of the literature. Prim. Care Companion CNS Disord. 2016, 18, 24032.
  9. Ellison, W.D.; Rosenstein, L.K.; Morgan, T.A.; Zimmerman, M. Community and Clinical Epidemiology of Borderline Personality Disorder. Psychiatr. Clin. N. Am. 2018, 41, 561–573.
  10. Capusan, A.J.; Yao, S.; Kuja-Halkola, R.; Bulik, C.M.; Thornton, L.M.; Bendtsen, P.; Marteinsdottir, I.; Thorsell, A.; Larsson, H. Genetic and environmental aspects in the association between attention-deficit hyperactivity disorder symptoms and binge-eating behavior in adults: A twin study. Psychol. Med. 2017, 47, 2866–2878.
  11. Cortese, S.; Bernardina, B.D.; Mouren, M.C. Attention-deficit/hyperactivity disorder (ADHD) and binge eating. Nutr. Rev. 2007, 65, 404–411.
  12. Hanson, J.; Phillips, L.; Hughes, S.; Corson, K. Attention-deficit hyperactivity disorder symptomatology, binge eating disorder symptomatology, and body mass index among college students. J. Am. Coll. Health 2019, 68, 543–549.
  13. Nazar, B.P.; Suwwan, R.; de Sousa Pinna, C.M.; Duchesne, M.; Freitas, S.R.; Sergeant, J.; Mattos, P. Influence of attention-deficit/hyperactivity disorder on binge eating behaviors and psychiatric comorbidity profile of obese women. Compr. Psychiatry 2014, 55, 572–578.
  14. Reinblatt, S.P.; Leoutsakos, J.-M.S.; Mahone, E.M.; Forrester, S.; Wilcox, H.C.; Riddle, M.A. Association between binge eating and attention-deficit/hyperactivity disorder in two pediatric community mental health clinics. Int. J. Eat. Disord. 2015, 48, 505–511.
  15. Bernardi, S.; Faraone, S.V.; Cortese, S.; Kerridge, B.T.; Pallanti, S.; Wang, S.; Blanco, C. The lifetime impact of attention deficit hyperactivity disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Psychol. Med. 2012, 42, 875–887.
  16. Philipsen, A.; Limberger, M.F.; Lieb, K.; Feige, B.; Kleindienst, N.; Ebner-Priemer, U.; Barth, J.; Schmahl, C.; Bohus, M. Attention-deficit hyperactivity disorder as a potentially aggravating factor in borderline personality disorder. Br. J. Psychiatry 2008, 192, 118–123.
  17. Sansone, R.A.; Chu, J.W.; Wiederman, M.W.; Lam, C. Eating disorder symptoms and borderline personality symptomatology. Eat. Weight. Disord. 2013, 16, e81–e85.
  18. Shaker, N.M.; Azzam, L.A.; Zahran, R.M.; Hashem, R.E. Frequency of binge eating behavior in patients with borderline personality disorder and its relation to emotional regulation and impulsivity. Eat. Weight. Disord. 2022, 27, 2497–2506.
  19. Miller, D.J.; Derefinko, K.J.; Lynam, D.R.; Milich, R.; Fillmore, M.T. Impulsivity and Attention Deficit-Hyperactivity Disorder: Subtype Classification Using the UPPS Impulsive Behavior Scale. J. Psychopathol. Behav. Assess. 2010, 32, 323–332.
  20. Nazar, B.P.; Bernardes, C.; Peachey, G.; Sergeant, J.; Mattos, P.; Treasure, J. The risk of eating disorders comorbid with attention-deficit/hyperactivity disorder: A systematic review and meta-analysis. Int. J. Eat. Disord. 2016, 49, 1045–1057.
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