Binge eating: ADHD, borderline personality disorder, and obesity

Abstract

Recent research in genomics, attention deficit/hyperactivity disorder (ADHD), autistic spectrum disorders (ASDs), and cognitive processing deficits has advanced our understanding of the relevance of personality, neurodevelopment, and binge eating to the ‘eating disorder spectrum’. Causal relations between eating disorders and personality disorders remain unclear. Family studies suggest an increase in ‘cluster B’ personality disorders in bulimia nervosa. Treatment models for bulimia and co-morbid borderline personality disorder (BPD) address the problem of ‘symptom substitution’ of bulimia with self-harm or addiction. Cognitive processing deficits link both conditions, and may be helped by cognitive remediation therapy and problem-solving therapy. ADHD and ASD are common neurodevelopmental disorders affecting impulse control and interpersonal relations. Preliminary studies suggest that 23% of patients with an eating disorder show features of ASD, and 17% have ADHD, although this may be a reflection of nutritional status. If confirmed, these findings have clinical implications and may explain treatment resistance. A mediating role for ADHD should be considered as a differential diagnosis in co-morbid BPD. Binge eating disorder (BED) may affect one in four obese patients, with a distinction between obesity and purging bulimia nervosa. Family studies suggest some shared vulnerability factors for obesity and BED, including genotype, but also divergence. National Institute for Health and Clinical Excellence guidelines on bariatric surgery for obesity require eating disorders to be addressed, and research indicates that eating disorders may predict the outcome of surgery. Research into cognitive processing, impulsivity, neurodevelopmental disorders, and genomics may help us better to match treatment to the patient.