Comorbid ADD with an Eating Disorder

The most common dilemma regarding an eating disorder and the diagnosis of ADD is either distinguishing between the two or deciding someone has both diagnoses. 

Without even thinking about risks of the medications and ulterior motives in attaining prescriptions of stimulants, the clinician needs to take any concerns with attention, organization and memory seriously.

The central issue is a simple question. Is the eating disorder itself causing the cognitive symptoms or is underlying ADD the culprit? Ultimately, both situations are extremely common, and the answer is not always obvious and often takes a long time to answer definitively.

If a patient’s eating disorder is dominant, then the next best step is to hold off on the diagnosis. All eating disorder symptoms (restricting, binging, purging, laxative abuse, over-exercising, etc.) can have a significant effect on cognitive function that can mimic ADD. In this situation, it’s best to keep open the possibility of this concurrent diagnosis and instead focus on recovery.

If a patient has been previously diagnosed with ADD using Neuropsychological testing, then the diagnosis is not in question. It may not be appropriate to use stimulants yet depending on the state of the eating disorder symptoms, but it’s also critical to state that these two diagnoses can exist together and may in fact be correlated.

If a patient has improved significantly from their eating disorder and continues to have symptoms that could be ADD, then it is imperative that the clinician consider this diagnosis.

One option is to do Neuropsychological testing, but these results are not as reliable in adults as in children and can be prohibitively expensive.

Another option is to start a trial of stimulants and to monitor both food and changes in attention carefully. Stimulants work quickly at the correct dose and also can be diagnostic. When effective, they can aid in emotional stability and eating disorder recovery.

Although the steps in considering and diagnosing ADD are fairly clear when stated objectively, the nuances of the actual diagnosis are often more cloudy. I’ll start to look into these complications in the next post.

Eating Disorders and ADD, Overview

One particularly thorny diagnostic conundrum when treating people with eating disorders is the overlap with attention deficit disorder.

This diagnosis is particularly complex for many reasons. First, it has been diagnosed much more readily in the last decade after being misdiagnosed or under-diagnosed for generations prior. Second, the diagnostic criteria are for children, and diagnosis in adults is controversial and lacks any clear standard for the clinician to follow. Third, it has become in a patient’s interest to seek this diagnosis for accommodations in school and for so called “neuroenhancers,” known clinically as stimulants like Adderall and Ritalin.

The confusing clinical territory and incidental personal gain make the diagnosis and treatment difficult for any clinician to navigate.

However, when treating people with eating disorders, another added wrinkle is that these medications also can cause appetite suppression and weight loss as side effects. This fact makes these prescriptions very appealing to this cohort of patients.

Even more confusing, the diagnosis of ADD in patients with eating disorders is clouded by the fact that poor nutrition, binging and purging can all cause cognitive side effects that mimic ADD. Thus, the diagnosis is almost impossible to determine in an adult with an eating disorder unless the ADD symptoms started first. 

The final piece of the puzzle is that for ADD is actually the primary diagnosis for a small number of patients with eating disorders. And for these patients, treating previously undiagnosed ADD actually cures the eating disorder. The eating disorder symptoms actually managed the overstimulation and inattention common with ADD. Once treated, these patients no longer need the eating disorder to cope. Although this group is very small, it does mean the clinician can’t rule out undiagnosed ADD for any eating disorder patient.

Due to the complex relationship between eating disorders and ADD, I will use the next several posts to delve further into these issues and cover the following topics:

1. The diagnosis of ADD in the context of an eating disorder
2. The use of stimulants for people with eating disorders
3. Risk of abuse of stimulants in people with eating disorders
4. Use of non-stimulant medications for people with eating disorders who have ADD
5. Stimulant use as a neuroenhancer or party drug
6. Taking patients in recovery off stimulants
7. Indecisiveness, a common symptom of ADD and it’s role in recovery

The Internal Struggle Between Illness and Recovery

How can it be that eating and being nourished are the ways to recover and that eating and weight change feels so bad?

For almost all illnesses, the process of getting better also feels better. People often gain strength, feel more hopeful and can think more about their future.

Eating disorder recovery rarely involves a sense of forward progress. Eating many times per day, each day, for one day after another feels painful at first.

The sense of loss of not being able to engage in eating disorder behaviors is akin to losing one’s fondest pleasure, most effective coping strategy and a sense of accomplishment. Eating disorder symptoms wreak havoc on people’s lives and simultaneously give structure and meaning to each and every day.

So the steps of recovery are always conflicting and painful, never straightforward and easy. The ambivalence of giving up a foundational part of one’s life and identity is a slow death, agonizing but necessary.

Other ways of coping with life don’t also cause sickness, weakness and even death. Living with eating disorders means a much smaller life with much less room for relationships, intimacy and fulfillment. Although if may feel like a safer life, it’s also a sick and sad one.

This means that recovery means not only the struggle to eat each day and fend off the urges to do eating disorder behavior, but also saying goodbye to a life and to a way of surviving. It means giving up something that feels like a part of your identity and who you are. It means deciding it is worth learning how to live a full life and not settle for a sick and small one.