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Comorbidity, Neurobiological Basis, and Clinical Management

Bulimia nervosa (BN) is an eating disorder characterized by recurrent binge eating followed by compensatory behaviors such as vomiting, laxatives, fasting, or excessive exercise. ADHD, a neurodevelopmental disorder marked by inattention, hyperactivity, and impulsivity, shares with BN alterations in inhibitory control and emotional regulation.

The coexistence of both disorders is frequent and clinically relevant: up to 31% of patients with eating disorders present ADHD symptoms, and the risk of BN in people with ADHD may be 4 to 6 times higher than in the general population. Comorbidity is more common in young women and is associated with greater severity and a worse prognosis.

Neurobiological and Psychopathological Basis

Dopaminergic and noradrenergic dysfunction: alterations in the prefrontal cortex and reward circuits, promoting impulsivity and the pursuit of immediate gratification.

Deficits in inhibitory control: difficulty stopping eating impulses in BN and impulsive behaviors in ADHD.

Emotional dysregulation: use of food as an escape strategy, coupled with generalized impulsivity.

Shared genetic factors: up to 90% of the covariance between ADHD symptoms and binge eating is explained by common inheritance.

Combined Clinical Manifestations

Increased frequency and intensity of binge eating and purging.

More marked weight fluctuations.

Poor therapeutic adherence due to inattention and disorganization.

High comorbidity with depression, anxiety, and substance abuse.

Diagnostic and Therapeutic Approach

Evaluation

Detailed clinical history from childhood.

Validated scales for ADHD in adults and structured interviews for eating disorders.

Treatment

Psychotherapy: Cognitive-behavioral therapy adapted for BN and emotional regulation training.

Pharmacotherapy: Stimulants (methylphenidate, lisdexamfetamine) for ADHD, with caution; SSRIs (fluoxetine) for BN, especially if depression is associated.

Multidisciplinary approach: psychiatry, psychology, nutrition, and internal medicine.

Prognosis and Recommendations

BN-ADHD comorbidity implies greater chronicity and risk of relapse, requiring integrated and prolonged interventions. Developing therapeutic strategies that simultaneously address impulsivity, emotional dysregulation, and eating habits is recommended, as well as conducting longitudinal studies to optimize prognosis.

Raul Ayala, MD