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Narcissistic Personality Disorder in Clinical Health Psychology Practice: Case Studies of Comorbid Psychological Distress and Life-Limiting Illness
Narcissistic Personality Disorder (NPD) is characterized by a persistent pattern of grandiosity, fantasies of unlimited power or importance, and the need for admiration or special treatment. Individuals with NPD may experience significant psychological distress related to interpersonal conflict and functional impairment. Research suggests core features of the disorder are associated with poor prognosis in therapy, including slow progress to behavioral change, premature patient-initiated termination, and negative therapeutic alliance. The current manuscript will explore challenges of working with NPD within the context of life-limiting illness for two psychotherapy patients seen in a behavioral health clinic at a large academic health science center. The ways in which their personality disorder affected their illness-experience shared significant overlap characterized by resistance to psychotherapeutic change, inconsistent adherence to medical recommendations, and volatile relationships with providers. In this manuscript we will (1) explore the ways in which aspects of narcissistic personality disorder impacted the patients’ physical health, emotional well-being, and healthcare utilization; (2) describe psychotherapeutic methods that may be useful for optimizing psychosocial, behavioral, and physical well-being in individuals with comorbid NPD and life-limiting disease; and (3) review conceptualizations of NPD from the DSM-5 alternative model for assessing personality function via trait domains.
Narcissistic Personality Disorder (NPD) is a psychological disorder characterized by a persistent pattern of grandiosity, fantasies of unlimited power or importance, and the need for admiration or special treatment. Core cognitive, affective, interpersonal, and behavioral features include impulsivity, volatility, attention-seeking, low self-esteem, and unstable interpersonal relationships 1 that result in a pervasive pattern of interpersonal difficulties, occupational problems, and significant psychosocial distress. Prevalence estimates of NPD range from 0 to 6.2% in community samples. 1 , 2 Of those individuals diagnosed with NPD, 50%–75% are male. 1 The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) 1 classifies NPD as a Cluster B (“dramatic, emotional, and erratic”) personality disorder, a category that also includes Antisocial, Borderline, and Histrionic Personality Disorders.
Individuals with NPD experience significant physical and mental health comorbidities and social problems. Stinson and colleagues 2 found high 12-month prevalence rates of substance abuse (40.6%), mood (28.6%), and anxiety (40%) disorders among participants with a diagnosis of NPD. Core features of NPD that contribute to these mental health comorbidities include a higher frequency of experiencing shame, helplessness, self-directed anger, higher admiration of self, 3 and impulsivity. 4 NPD is a significant predictor of (a) making multiple suicide attempts, 5 (b) using lethal means to attempt suicide, 6 and (c) making suicide attempts in proximal relationship to being fired or experiencing domestic, financial, or health-related problems. 7 Regarding physical health outcomes, individuals with Cluster B personality disorders, including NPD, have demonstrated significantly higher mortality rates due to cardiovascular disease than those without personality disorders, even after controlling for relevant medical comorbidities. 8 , 9 NPD specifically is also associated with gastrointestinal conditions. 9 Not unexpectedly, NPD is strongly associated with high health care utilization across a variety of services. 8 , 10 Additionally, provider-patient relationships among individuals with NPD can be challenging due to interpersonal dysfunction marked by dramatic, emotional, and erratic thinking and/or behavior. From a behavioral standpoint, individuals with a Cluster B diagnosis are more likely to have (a) a criminal conviction (b) spent time in prison, (c) a history of interpersonal violence, 8 (d) caused pain or suffering to others, 8 and (e) evidenced overall impairment in social role functioning. 8
In terms of treatment, a limited body of research has investigated interventions for NPD using randomized controlled trials or other methodologically rigorous approaches. One systematic review published by Town and colleagues 11 found eight studies of “moderate” scientific rigor that demonstrated the positive effect of short-term psychodynamic psychotherapy (STPP). Several researchers have examined the impact of NPD on the psychotherapeutic relationship. 12 – 14 Tanzilli and colleagues 14 found that individuals treating patients with NPD were more likely to experience negative counter-transference feelings of disengagement as well as feeling criticized or mistreated. These authors highlight the core feature of narcissism—struggle to form intimate relationships—as a significant barrier to positive treatment outcome, due to the patient’s potential inability to form a safe and trusting relationship with the therapist. Other researchers have found that individuals with NPD have higher rates of self-terminating treatment. 15
One proposed treatment method for personality disorders was originally developed with the goal of providing brief psychological services to individuals with substance use disorders or medical nonadherence concerns. This approach revolves around the six-component “FRAMES” technique developed by Miller and Sanchez. 16 This method emphasizes the role of Feedback, Responsibility, Advice, Menu of Strategies, Empathy, and Self-Efficacy. This approach highlights guidelines for the patient and therapist in order to maximize the likelihood of behavioral change and therapeutic progress. 16 , 17 This strategy creates a structure in which the provider can limit the impact of transference and countertransference on the therapeutic process and focus on creating a team-oriented dynamic that is supported by limit-setting, strong boundaries, and minimization of “splitting” with other providers.
The following case studies describe the particular challenges of working with two adult patients with NPD in a clinical health psychology practice within a large academic health center in the Southeast United States.
Reasons for referral and presenting problems
Mr. X is a middle-aged, Caucasian male who was referred to the Psychology Clinic for assessment and treatment of depression. Medical record review revealed a complex medical and psychiatric history including several acute illnesses, multiple psychological conditions, a history of suicidality and involuntary psychiatric admission, as well as lack of adherence to behavioral recommendations regarding diet, exercise, and medication compliance. Approximately one year prior to his intake at our clinic, Mr. X experienced a life-threatening medical crisis. He noted that he hoped psychotherapy would support him in the goal of finding new meaning in his life.
At the time of his initial intake, Mr. X presented to the Psychology Clinic with an unusually long list of medical and mental health diagnoses. His primary concern during the initial phase of his treatment was depression. Although Mr. X’s unique personality was appreciated immediately, it was not until many months into treatment when behavioral patterns suggestive of a personality disorder emerged. After recognizing Mr. X’s pattern of volatile interpersonal encounters that was suggestive of either Borderline Personality Disorder or Narcissistic Personality Disorder (according to the guidelines explicated in the DSM-5), other symptoms indicative of NPD began emerging, particularly when standard treatment approaches were met with resistance and individual appointments often turned into crisis management sessions. The most salient features of NPD that interfered with Mr. X’s treatment progress were thoughts of grandiosity, need for admiration or special treatment, and fantasies of unlimited power or importance. For example, Mr. X regularly cancelled therapy sessions the same day of his appointment due to vague complaints; when he returned to session, he elaborated on these concerns with excessive detail in an attention-seeking manner. Similarly, his referral physician reported feeling compelled by Mr. X to treat him for unsubstantiated medical complaints.
Mr. X initiated his first session by describing the many “illustrious” mental health providers from whom he had received treatment. He described his goals for psychotherapy, which included growing his religious faith and practice, exploring lifelong questions regarding intimacy, and increasing the size of his social network. Mr. X engaged in two years of individual cognitive-behavioral therapy marked by numerous distractions that impaired his ability to focus on broader values-based treatment goals. Although efforts were made to assist him in gaining insight into the way in which personality factors influenced behavioral patterns and interpersonal difficulties, Mr. X benefitted primarily from concrete treatment approaches designed to address specific behavioral problems (i.e., poor adherence to medical recommendations).
Ms. Y is a middle-aged, Caucasian female who was referred by her oncologist for evaluation and management of distress in the context of diagnosis and treatment of cancer. Ms. Y presented for cancer treatment from out-of-state after seeking treatment recommendations from multiple well-known cancer centers throughout the United States. She was reportedly counseled by each facility that seeking multiple opinions would delay treatment and result in disease advancement and shortened survival. One center declined to treat her, as they believed that she did not seem able to engage in a collaborative relationship with medical team members. Once Ms. Y began treatment at our facility, she sought medical care for vague or minor symptoms from almost every department in our medical center. While her cancer diagnosis and potential side effects of treatment were well-documented, Ms. Y demonstrated a pattern of attention-seeking behavior, similar to that displayed by Mr. X, in which hypervigilance about minute changes in physical sensation or function were treated like emergencies that required urgent care. Ms. Y’s social history was remarkable for having a young child of whom she lost custody, multiple ex-boyfriends with whom she had tumultuous relationships, a current boyfriend, and a very supportive mother. Ms. Y reported receiving but not completing graduate medical training. Medical record review revealed the additional history that she was dismissed from graduate training and barred from seeking a health care practitioner license in several states due to academic and professional behavior issues.
Features of a personality disorder emerged within minutes of beginning Ms. Y’s intake in our training Clinic. Once settled in the interview room, Ms. Y called the trainees “incompetent,” and insisted that she would only see “the Attending.” Once the Attending Psychologist entered the room, she cried out loudly that she felt as if she had been sexually victimized. Upon clarification, she explained that this was in reference to being asked by a male health care provider to disrobe and change into a medical gown for a CT scan several months ago. This highly atypical and dramatic presentation, in conjunction with her reported history of exceptionally volatile interpersonal relationships, immediately alerted our team to the high likelihood of the presence of a severe personality disorder. Our medical record review and diagnostic interview yielded concrete evidence in support of a personality disorder diagnosis with prominent NPD features. Ms. Y provided a plethora of personal anecdotes, which further supported this diagnosis. Conceptualizing her case from within an NPD framework brought awareness and appreciation of the unique challenges of working with individuals with this disorder. This was a crucial initial step toward assisting Ms. Y with her primary goal of achieving and maintaining the interpersonal stability necessary to complete cancer treatment. Her self-reported history and behavior in the Clinic were consistent with key features of NPD, including relational volatility, excessive demands for special treatment, disdain for others’ emotional experiences, and lack of empathy. Moreover, her tendency toward hypersensitivity and negative automatic thought patterns regarding perceived insults from most individuals with whom she came into contact, including medical providers with whom she needed to collaborate in order to obtain life-preserving cancer treatment, resulted in persistently paranoid ideation. These symptoms of NPD caused her distress and served as barriers to obtaining successful medical and psychological treatment. As an aside, Mr. X demonstrated similar tendencies toward paranoia in terms of presuming that even subtle changes within the dynamics of existing interpersonal relationships were indicative of negative underlying motivations on the part of others. For both patients, this resulted in volatile relationships in personal and medical contexts.
Interestingly, Ms. Y herself confirmed a prior personality disorder diagnosis—which she referred to as “mixed personality disorder” with narcissistic features—within the context of discussing her history of difficult relationships with medical providers. However, Ms. Y did not provide specific information as to when, by whom, or under what criteria she had received this diagnosis. Ms. Y also disclosed anxiety about maintaining collaborative relationships with her treatment team. She expressed uncertainty about her ability to manage her distress related to her diagnosis, grief over interpersonal losses, and worry about the effects of cancer and treatment on her self-esteem, body image, and sexual functioning. Given that Ms. Y intended to move back to her residence in another state upon completion of her cancer treatment, brief therapy was indicated. The main goal of treatment was to increase Ms. Y’s capacity for distress tolerance so that she would be able to complete intensive cancer treatment. A secondary goal was to provide her with a positive psychotherapy experience in order to assist her with transitioning to longer-term psychological treatment upon her return home. She attended four, 50-minute, cognitive-behavioral therapy sessions. She achieved her goal of managing her distress in a manner that allowed her to complete her cancer treatment successfully. Given the brevity of the treatment that she received, we were unable to target major mood disturbance or core personality features. Thus, depression was not significantly reduced. However, she experienced a reduction in hopelessness and a remission in suicidal ideation during the course of her treatment. She also expressed that she had an overall positive experience in therapy and noted that she wished to pursue additional sessions upon return for routine follow-up care.
The following discussion highlights two crucial aspects of understanding NPD within Clinical Health Psychology practice: (1) how NPD manifests within psychotherapy in health care settings, and (2) specific ways in which these cognitive-behavioral patterns interfere with both medical and psychological treatment progress among individuals with NPD. Key ways in which NPD manifests in psychotherapy from a cognitive behavioral standpoint include: superlative self-talk and self-aggrandizement, expectations of special treatment, poor behavioral health adherence and difficult relationships with providers, and low distress tolerance. These aspects of the patients’ interpersonal style negatively affected treatment due to: poor boundaries with the therapist, ambivalence about change associated with fragile self-esteem, cognitive distortions (i.e., black-and-white thinking), and help-rejecting behaviors. An additional barrier to treatment progress underlying each of the above issues resulted from both patients’ tendency toward hypersensitivity and paranoia in therapy and in their everyday lives; both patients experienced interpersonal instability due to perceived insults and injuries of varying seriousness, which emphasized content that is clearly tied to core beliefs associated with narcissistic pathology.
Manifestations of NPD in brief and long-term psychological treatment
Superlative self-talk and self-aggrandizement.
Mr. X revealed a persistent pattern of self-glorification and a need to highlight his exceptional uniqueness in therapy. Over the course of his treatment, he repeatedly mentioned his “genius IQ,” his prodigious talents, and his exceptional ability to help others in need. Early in treatment he expressed concern regarding whether his therapist would be able to handle the complexities of his life story. He displayed a sense of self-satisfaction while relaying shocking, fantastical, or dramatic anecdotes from his life in which he often was the victim of disappointing circumstances or betrayal. He returned often to the idea that he was destined for some great purpose.
Ms. Y evidenced similar self-aggrandizement, including making frequent statements such as “I know I’m brilliant” and “I know more than [my medical providers] about my cancer treatment.” Her exaggerated self-worth was evident also in her perception of herself as highly sexually desirable to both men and women, especially those who are of high-status. Consistent with this, she reported a history of engaging in sexualized discourse and sexual relationships with health care providers and other professionals with whom she was under contract as well as a history of being sexually victimized/harassed by such individuals with pending litigation.
Expectation of special treatment
Mr. X repeatedly arrived 20 minutes early to his psychotherapy sessions seeking extra attention and lingering after his check-in to chat with Clinic staff. He frequently requested that the therapist extend his sessions, schedule additional sessions per week, and/or return multiple calls outside of session per week. Throughout treatment, Mr. X reminded the therapist about the celebrated health care providers with whom he had worked. He repeatedly compared his care to the services he received for many years at a prestigious medical school. He also noted even the slightest inconveniences he encountered at the Clinic, such as difficulty finding parking or not having a call returned quickly enough.
During treatment, Ms. Y would call at her appointment time to indicate that she would be 30 minutes late. However, when her appointment was rescheduled for that time, she would then arrive 30 minutes late to that appointment. As noted previously, she declined to receive services from pre-doctoral trainees due to their “incompetence” and expected that she would receive services solely from the Attending Psychologist, whose credentials she closely queried. Although she agreed to be treated by a postdoctoral trainee for therapy, she repeatedly advised the therapist that she found her care in the clinic unsatisfactory due to our department being “weak.” Expectations for special treatment extended to her cancer treatment team. Ms. Y demanded to receive cancer treatment on a federal holiday when the cancer center was closed. In addition, she used the oncology on-call service to obtain after-hours consultation about minor, nonurgent concerns, such as losing several tenths of a pound of weight.
Poor behavioral health adherence and difficult relationships with health care providers
Mr. X frequently failed to engage in self-care behaviors that were crucial to maintaining his health, such as dietary restrictions, CPAP usage, fluid intake management, consistent medication usage, and the wearing of compression socks. Additionally, Mr. X frequently alternated between idealizing and devaluating his physicians and their teams such that they were either at the top of their fields or completely inept. Mr. X often, to his own detriment, disagreed with his providers’ treatment plans and/or the manner in which they delivered care. For example, his cardiologist recommended that he discontinue use of a particular medication prior to completing a cardiac stress test. However, Mr. X decided that it would not be safe to stop using this medication. He also refused to complete the stress test due to concern that he would have a heart attack. Although Mr. X’s anxiety about the risks associated with this procedure was abundantly clear, he attributed his actions to superior knowledge of his body as compared to his medical providers.
Ms. Y sought multiple consultations regarding the management of her cancer, both prior to and during her treatment at our facility. She reported that several previous medical providers had discharged her from care due to her inappropriate behavior and an inability to form collaborative working relationships. She reported feeling abandoned by these providers, who she described as incompetent. She also noted that she filed complaints against them with state medical boards. At our facility, she was insistent upon receiving a new, highly specialized, and difficult-to-access cancer treatment. However, the oncology team at our facility did not recommend this treatment for her, which she repeatedly questioned and viewed as incompetence. This pattern of idealization and devaluation was also evident in therapy. When the therapist responded to Ms. Y’s suicidal ideation by conducting a risk assessment, Ms. Y stated that this was a waste of time and an indicator that the therapist was incompetent. Although the therapist was able to navigate these conflicts in a way that maintained the therapeutic relationship, Ms. Y continued to criticize the therapist and emphasize her dissatisfaction with her care.
In contrast to Mr. X, who struggled with adherence, Ms. Y was remarkably adherent to her cancer treatment and providers’ recommendations. This may have been at least partly due to the fact that her providers engaged her fully in her treatment planning and acknowledged and honored her objectively high level of knowledge about her cancer and its treatment.
Low distress tolerance
Mr. X demonstrated significant difficulty with tolerating ambiguous emotional experiences in which his self-worth was challenged. He frequently referred to difficult emotional experiences as “crises” and appeared to rely on the therapist rather than develop his own internal stress management skillset. Throughout treatment, Mr. X relayed multiple scenarios in which the experience of vulnerability in interpersonal relationships led to a pattern of emotionally charged, rapidly escalating encounters that almost always led to the demise of the relationship in question. Mr. X attempted to replicate this pattern several times with the therapist when he felt threatened by therapeutic challenges and/or boundary setting.
Similarly, Ms. Y was observed to experience difficulties with emotion regulation and distress tolerance. She described the possibility of not receiving the specialized cancer treatment that she was seeking as “the biggest regret of my life.” She indicated that routine clinical situations, such as being asked to disrobe and wear a hospital gown, were traumatic and sexually violating. Her affect was intense, dramatic in presentation, and out of proportion to events experienced. Her high level of distress prompted her to engage in excessive health care utilization and to expect that her concerns would be addressed immediately and fully. While undergoing medical treatment, she was experienced by clinical support staff on one occasion as aggressive and threatening. Outside of relationships with medical providers, Ms. Y endorsed a long history of volatile relationships with romantic partners, employers, and attorneys.
Challenges associated with NPD in psychological treatment
Mr. X frequently challenged normative therapist-patient boundaries. He called the therapist excessively between sessions, requested extra time during his sessions, and insisted on giving the therapist a holiday gift. When presenting the therapist with a box of chocolates, Mr. X stated, “I know you are not supposed to accept presents, but you have no choice and will be taking that home with you.” He frequently made comments to the therapist in which he acknowledged a rule or boundary and then appeared to take pleasure in crossing these lines. Mr. X consistently treated the therapist overly informally, often complimenting her clothing, asking an increasing number of personal questions, or cursing during session.
Ms. Y also experienced difficulties with establishing and maintaining appropriate interpersonal boundaries in professional relationships. In particular, her rigidly held beliefs regarding the inferiority of a wide variety of groups of individuals threatened her ability to form respectful and effective relationships with diverse employers and health care providers. During her second therapy session, Ms. Y openly stated that the therapist’s country of origin and accent were problematic for her, noting that she had previously received substandard health care from individuals born outside the United States. The therapist used this opportunity to explore with Ms. Y how observing firm, prescribed boundaries with her health care providers could enhance her health care outcomes.
Ambivalence about change
Another prominent theme in Mr. X’s treatment revolved around his ambivalence regarding therapeutic change. Mr. X frequently asked the therapist to challenge him in certain ways and then responded negatively upon being challenged. When given therapy homework assignments, Mr. X frequently did not complete them; instead, he insisted on editing published worksheets, and/or amending the guidelines for prescribed exercises. He often identified therapeutic goals but strayed from them when discussions touched on painful subjects. Notably, Mr. X demonstrated particular difficulties with being interrupted. During some sessions, he lightheartedly noted that he was aware of his tendency to be verbose and gave the therapist “permission” to cut him off if he was being overly tangential. However, other times he became defensive and angry when the therapist attempted to redirect him without his permission. Mr. X’s inconsistent response to interruptions revealed a sense of ambivalence regarding his participation in the therapeutic process.
In contrast to Mr. X, Ms. Y expressed awareness of her personality structure and articulated strong motivation to mitigate her distress, complete her cancer treatment, and achieve future goals, such as seeing her child graduate from college. The value she placed on the role of motherhood, coupled with the life threat of a cancer diagnosis, appeared to be primary motivators for change.
Consistent with firmly held beliefs about his specialness, Mr. X revealed a pattern of negative, all-or-nothing thought processes. He frequently struggled to see multiple perspectives on an issue and devalued others who were not able to see his perspective. This tendency resulted in a vicious cycle of unrealistic goal-setting, feelings of failure, and low mood which often impaired his ability to make progress in treatment.
Ms. Y also expressed a number of distorted beliefs about herself, her world, and her future. Her inflated self-concept did not appear to be grounded within objective academic, employment, or interpersonal histories. Additionally, she held many negative expectations of others based on distorted beliefs about how individuals from various socioeconomic, educational, and demographic backgrounds think, feel, and behave. These beliefs led to significant emotional dysregulation, poor distress tolerance, and interpersonal chaos with her medical providers and others in her life.
Mr. X frequently engaged in self-sabotaging behavior related to treatment goals. He cancelled almost the same number of scheduled sessions that he had completed over a two year period. He often maintained that the cancellations were due to medical exacerbations but later revealed that he was experiencing some sort of psychosocial distress. Mr. X also became angry with his medical providers due to his preoccupation with minor details regarding the speed and efficiency with which they served him. After a particularly emotional session during which the therapist encouraged Mr. X to explore his feelings surrounding one of his greatest life regrets, Mr. X called the Clinic and reported that he needed to speak to his therapist’s supervisor and to be assigned a new therapist. Mr. X lashed out at the therapist via her supervisor by questioning her competency. However, after several delicate discussions, Mr. X resumed work with the therapist. He spent months dramatically alluding to difficulties in trusting the therapist and the burden of rebuilding the therapeutic relationship.
Ms. Y’s pursuit and then rejection of cancer treatment recommendations from numerous cancer centers across the United States is consistent with help-rejecting behavior that occurs in NPD. However, once she decided to receive care at our facility, she was observed to be adherent to her treatment recommendations and actively engaged in her own care.
Summary of results
These cases demonstrate the complex relationship between manifestations of NPD and challenges to psychotherapeutic progress in a hospital-based clinical and health psychology practice. Mr. X and Ms. Y both demonstrated features of NPD during the course of their treatment. Mr. X indicated during his first session that he sought long-term psychotherapy in response to recovering from a medical crisis and re-evaluating his goals moving forward. Although he experienced many personality-based barriers to progress in psychotherapy, he was able to work through multiple therapeutic ruptures and maintain a strong relationship with the student therapist that was grounded in humor, authenticity, and direct communication. He also demonstrated some growth in personal insight regarding the ways in which his tendency toward black-and-white thinking affects his mood and daily function, particularly in terms of his relationships. However, in many ways, his dramatic and avoidant tendencies precluded his ability to make prominent changes in worldview or interpersonal style.
Ms. Y, on the other hand, entered treatment when in the throes of a perceived medical crisis due to distress associated with her cancer diagnosis and a lack of confidence in her ability to manage the complex emotions associated with a potentially life-threatening illness. At the time of her referral, her medical team’s primary goal was to reduce her stress and improve her emotion regulation enough that she would be able to engage in an appropriate manner with her medical team in order to successfully complete her cancer treatment. Unlike Mr. X, it did not appear as if Ms. Y sought long-term, deep, existential therapy that would allow her to explore her complex history or goals for the future. Therefore her treatment was more problem-focused in order to reduce barriers to successful cancer treatment.
As previously reflected, treatment challenges for patients with NPD in clinical health psychology include: (1) poor boundaries, (2) ambivalence about change, (3) cognitive distortions, (4) idealizing and devaluing providers, (5) poor behavioral health adherence, and (6) help-rejecting behaviors. Table 1 summarizes psychotherapy treatment challenges related to key features of NPD and identifies how these behaviors were demonstrated by each patient.
Behavioral examples of treatment challenges in clinical health psychology practice.
The cases discussed above highlight many prominent features of NPD as displayed by two patients receiving psychotherapy in a clinical health psychology practice within an academic teaching hospital. These patients shared a lifelong history of distress associated with unmet expectations, unrealized goals, and unfulfilling relationships. Both patients had sought psychotherapy and pharmacologic treatment throughout their lives and both presented to our clinic seeking support while dealing with chronic and potentially life-limiting illnesses. While there were many shared experiences between these two patients, there were some crucial differences. Mr. X explicitly sought long-term supportive therapy, while Ms. Y engaged in brief, problem-focused treatment. Mr. X was socially isolated and estranged from all living family members, while Ms. Y maintained a close, emotionally supportive relationship with her mother. Additionally, Mr. X demonstrated significant resistance to behavior change as manifested by inconsistent attendance, poor homework completion, avoidance of emotionally difficult topics, and lashing out at the therapist when he felt she had offended him. However, Ms. Y was motivated and receptive to treatment. Although her depressive symptoms did not resolve over the course of her brief treatment, her sense of hopelessness and suicidal ideation both decreased.
These cases highlight the complex experiences of individuals with NPD and those who work with them in clinical settings. The similarities in these cases offer support for core features of NPD as a unique condition, while the differences in their life experiences is suggestive of the variability that may affect psychological treatment course and outcomes. Mr. X made some progress on therapeutic goals but continued to be limited in his ability to engage on a deeper level due to ongoing medical management issues and psychological avoidance. Ms. Y terminated treatment after four sessions. However, psychological treatment may have played a crucial role in her ability to manage distress while enduring the challenges of cancer treatment.
A prominent challenge in the conceptualization of NPD cases revolves around the heterogeneity in presentation of the disorder and significant symtomatologic overlap with other Cluster B personality disorders. In particular, the DSM-5 Cluster B disorders share significant symtomologic overlap in terms of excessive attention-seeking, emotion dysregulation (i.e., impulsive rage), inappropriate sexual behavior, and unstable views of others (i.e., fluctuating between idealizing and devaluing). 1 Consistent with this, although NPD diagnoses were favored for Mr. X and Ms. Y, both demonstrated features of Histrionic Personality Disorder, Borderline Personality Disorder, and Antisocial Personality Disorder. However, both patients’ most prominent, distressing, and impairing symptoms and behaviors were those that are unique to the DSM-5 diagnostic criteria for NPD (i.e., arrogance, grandiosity, and need for admiring attention). Further, both patients demonstrated a relative stability of self-image, a relative absence of deceit, and a relative lack of conduct disorder/criminal history, 1 suggesting an absence of several defining features of Borderline Personality Disorder and Antisocial Personality Disorder. As such, NPD diagnoses appeared to best account for these patients’ distress and impairment at the time of presentation for treatment. However, it is possible that other Cluster B disorders may be more prominent for these patients in different circumstances (i.e., health vs. family stressors).
The diagnostic framework used to explore pathological narcissism in the above cases was organized according to the DSM-5 criteria. 1 These criteria were developed with an underlying assumption that personality disorders can be characterized into independent clusters and independent clinical syndromes. Recent consideration has been given to an alternative model. Working under the assumption that personality disorders have significant clinical overlap, the dimensional approach argues that pathological personality features may represent a wide range of fluid presentations that begin with normal personality function. This alternative model is explicated in an appendix to the DSM-5 and describes the ways in which personality function may vary between individuals on four dimensions: Identity, Self-Direction, Empathy, and Intimacy. Additionally, further consideration is made regarding personality function on five dimensional scales: negative affectivity, detachment, antagonism, dis-inhibition, and psychoticism. 1 The exploration of these dimensional scales may allow clinicians to conceptualize patients in a way that they are able to work around limitations in categorical diagnostic criteria in order to improve the likelihood of symptom reduction and improved quality of life.
A brief reconceptualization of Mr. X and Ms. Y’s histories from within the new model of personality disorders allows us to examine their personalities within the domains described and to rate their level of dysfunction from 0 (Little or no impairment) to 4 (Extreme Impairment). This system allows clinicians to assess symptoms at multiple levels of emotional function rather than being forced to identify a single disorder that captures the entirety of the patient’s history and present difficulties. This system is also useful in addressing the problem of overlap among within-cluster disorders.
Overall these case studies and the literature reviewed highlight: (1) the importance of provider familiarity with personality disorder symptom profiles and evaluation, (2) the significance of personality disorders in affecting medical and psychological treatment course and outcomes, (3) the potential impact of treating personality disorders on provider function and well-being, and (4) potential future directions for research on how to improve treatment outcomes for individuals with personality disorders, and NPD specifically, where obstacles to forming the crucial therapeutic alliance may have a critical impact on patient prognosis.
- Open access
- Published: 23 November 2023
Risk factors associated with newly diagnosed attention-deficit/hyperactivity disorder in adults: a retrospective case-control study
- Jeff Schein 1 ,
- Martin Cloutier 2 ,
- Marjolaine Gauthier-Loiselle 2 ,
- Rebecca Bungay 2 ,
- Emmanuelle Arpin 2 ,
- Annie Guerin 2 &
- Ann Childress 3
BMC Psychiatry volume 23 , Article number: 870 ( 2023 ) Cite this article
Knowledge of risk factors for attention-deficit/hyperactivity disorder (ADHD) may facilitate early diagnosis; however, studies examining a broad range of potential risk factors for ADHD in adults are limited. This study aimed to identify risk factors associated with newly diagnosed ADHD among adults in the United States (US).
Eligible adults from the IQVIA PharMetrics® Plus database (10/01/2015-09/30/2021) were classified into the ADHD cohort if they had ≥ 2 ADHD diagnoses (index date: first ADHD diagnosis) and into the non-ADHD cohort if they had no observed ADHD diagnosis (index date: random date) with a 1:3 case-to-control ratio. Risk factors for newly diagnosed ADHD were assessed during the 12-month baseline period; logistic regression with stepwise variable selection was used to assess statistically significant association. The combined impact of selected risk factors was explored using common patient profiles.
A total of 337,034 patients were included in the ADHD cohort (mean age 35.2 years; 54.5% female) and 1,011,102 in the non-ADHD cohort (mean age 44.0 years; 52.4% female). During the baseline period, the most frequent mental health comorbidities in the ADHD and non-ADHD cohorts were anxiety disorders (34.4% and 11.1%) and depressive disorders (27.9% and 7.8%). Accordingly, a higher proportion of patients in the ADHD cohort received antianxiety agents (20.6% and 8.3%) and antidepressants (40.9% and 15.8%). Key risk factors associated with a significantly increased probability of ADHD included the number of mental health comorbidities (odds ratio [OR] for 1 comorbidity: 1.41; ≥2 comorbidities: 1.45), along with certain mental health comorbidities (e.g., feeding and eating disorders [OR: 1.88], bipolar disorders [OR: 1.50], depressive disorders [OR: 1.37], trauma- and stressor-related disorders [OR: 1.27], anxiety disorders [OR: 1.24]), use of antidepressants (OR: 1.87) and antianxiety agents (OR: 1.40), and having ≥ 1 psychotherapy visit (OR: 1.70), ≥ 1 specialist visit (OR: 1.30), and ≥ 10 outpatient visits (OR: 1.51) (all p < 0.05). The predicted risk of ADHD for patients with treated anxiety and depressive disorders was 81.9%.
Mental health comorbidities and related treatments are significantly associated with newly diagnosed ADHD in US adults. Screening for patients with risk factors for ADHD may allow early diagnosis and appropriate management.
Peer Review reports
Attention-deficit/hyperactivity disorder (ADHD) is a debilitating neurodevelopmental condition with an estimated prevalence of 4.4% among adults in the United States (US) [ 1 ]. ADHD is traditionally perceived as a childhood disorder [ 2 ]; hence, underdiagnosis, delayed diagnosis, and undertreatment of ADHD are believed to be common among adults [ 3 , 4 ].
The diagnostic challenges of ADHD are partially attributable to the frequent comorbid mental disorders [ 5 , 6 ]. Certain mental health comorbidities, such as anxiety and depressive disorders, share overlapping symptoms with ADHD [ 7 , 8 ], potentially leading to misdiagnosis or delayed diagnosis. Studies have suggested that about one-fifth of adults seeking psychiatric services and reporting for other mental health conditions were later found to have ADHD [ 9 , 10 , 11 ]. The World Health Organization Mental Health Survey has also reported that among US adults with ADHD identified through diagnostic interviews, approximately half had received some form of treatment for their emotional or behavioral problems in the past year, but only 13.2% were treated specifically for ADHD [ 12 ]. Clinicians’ lack of awareness or training on adult ADHD may also hinder ADHD diagnosis [ 4 ]. A US medical record-based study found that 56% of adults with ADHD had not received a prior diagnosis of the condition despite complaining about ADHD symptoms to other healthcare professionals in the past [ 13 ]. Other reasons adding to the diagnostic challenge of ADHD in adults may include patient’s fear of stigma and masking behaviors developed over the years [ 4 , 14 ].
ADHD is associated with a wide range of psychosocial, functional, and occupational problems in adults [ 15 ]. A delay in diagnosis, or undiagnosed and ultimately untreated ADHD, may lead to poor clinical and functional outcomes even if comorbidities are treated [ 16 ]. Conversely, early identification of ADHD may allow better symptom management and improve patient functioning and quality of life. To facilitate diagnosis, risk factors are commonly used to predict disease development and aid clinicians to identify at-risk patients [ 17 ]. However, there is a paucity of large studies examining a broad range of potential risk factors for an ADHD diagnosis in adults. Prior studies have reported certain patient characteristics, such as presence of anxiety disorders, depressive disorders, sleep impairments, eating disorders, and childhood illnesses or health events (e.g., obesity, head injuries, infections) that may be associated with ADHD [ 18 , 19 , 20 , 21 , 22 , 23 ]. Yet, most of these studies have examined a single or a few factors, and many were conducted in pediatric ADHD populations primarily outside of the US.
Knowledge on patient characteristics associated with a higher risk of ADHD in adults and the patient journey prior to a clinical ADHD diagnosis may facilitate early diagnosis and the provision of appropriate management. The current study was conducted to identify risk factors for newly diagnosed ADHD in adult patients using a large claims database in the US. The potential utility of the results was also demonstrated through exploring the combined impact of selected risk factors on ADHD risk prediction using fictitious common patient profiles.
Data from the IQVIA PharMetrics® Plus (IQVIA) database covering the period of October 1, 2015, to September 30, 2021, were used. The IQVIA database contains integrated claims data of over 190 million beneficiaries across the US and includes information on inpatient and outpatient diagnoses and procedures, prescription fills, patients’ pharmacy and medical benefits, inpatient stays, and provider details. Additional data elements encompass dates of service, demographic variables, plan type, payer type, and start and stop dates of health plan enrollment. Data are de-identified and comply with the patient requirements of the Health Insurance Portability and Accountability Act (HIPAA); therefore, no review by an institutional review board nor informed consent was required per Title 45 of CFR, Part 46.101(b)(4) [ 24 ].
Study design and patient populations
A retrospective case-control study design was used. Eligible adults were classified into two cohorts based on the presence of ADHD diagnoses (International Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10-CM] F90.x): the ADHD cohort comprised patients with ≥ 2 ADHD diagnoses recorded on a medical claim on distinct dates at any time during their continuous health plan enrollment; and the non-ADHD cohort comprised patients without any ADHD diagnoses recorded on a medical claim at any time during their continuous health plan enrollment. To account for large differences in sample size and to retain statistical power, a 1:3 case-to-control ratio was used. Specifically, eligible patients were randomly selected into the non-ADHD cohort such that the total number of patients in the non-ADHD cohort was three times that of the ADHD cohort.
The index date was defined as the first observed ADHD diagnosis among the ADHD cohort and a randomly selected date among the non-ADHD cohort. To allow sufficient time to capture potential risk factors for ADHD, patients were required to have ≥ 12 months of continuous health plan enrollment prior to the index date. The baseline period was defined as the 12 months pre-index.
Study measures and outcomes
Patient characteristics and potential risk factors for newly diagnosed ADHD were assessed during the baseline period for each cohort, separately. Potential risk factors considered in this study were identified through a targeted literature review and observable variables in the data and included demographic characteristics (i.e., age, sex, regions of residence, calendar year of index date), clinical characteristics (i.e., physical and mental health comorbidities), pharmacological treatments (i.e., medications for common ADHD comorbidities), healthcare resource utilization (i.e., number of psychotherapy, inpatient, emergency room, outpatient, and specialist [psychiatrist, neurologist] visits). Risk factors for ADHD in this study were identified from potential risk factors that had statistically significant association with newly diagnosed ADHD, as described in the next section.
Descriptive statistics were used to summarize baseline patient characteristics and potential risk factors for newly diagnosed ADHD. Means, medians, and standard deviations (SDs) were reported for continuous variables; frequency counts and percentages were reported for categorical variables.
Univariate statistics were used to compare potential risk factors between the ADHD and non-ADHD cohorts. The magnitude of the difference between cohorts was assessed by calculating the standardized differences (std. diff.) for both continuous and categorical variables.
Logistic regression model with stepwise variable selection was used to assess statistically significant association between potential risk factors and ADHD diagnosis. Potential risk factors were eligible for inclusion in the logistic regression based on their univariate association with ADHD diagnosis (i.e., std. diff. >0.10). Potential risk factors presented in < 0.5% of the sample were discarded. Variables included in the last iteration of the stepwise selection process were considered as risk factors of the study outcome. The association between risk factors and ADHD diagnosis were reported as odds ratios (ORs) along with their 95% confidence intervals (CIs) and p-values.
To facilitate the interpretation of the regression analyses, the predicted risk of ADHD based on regression coefficient estimates was evaluated for six fictitious common patient profiles corresponding to patients who harbor selected combinations of ADHD risk factors. This exploratory analysis allowed for the estimation of how the risk of having ADHD would vary had the same person had additional risk factors but otherwise the same characteristics.
Patient characteristics and potential risk factors
The total sample comprised 1,348,136 patients, including 337,034 in the ADHD cohort and 1,011,102 in the non-ADHD cohort (Fig. 1 ). Table 1 presents the patient characteristics and potential risk factors (i.e., characteristics with a std. diff. >0.10) by cohort.
Sample selection flowchart. ADHD, attention-deficit/hyperactivity disorder; ICD-10-CM, International Classification of Diseases, Tenth Revision, Clinical Modification
1 ADHD was defined as ICD-10-CM codes: F90.x
2 Eligible patients were randomly selected into the non-ADHD cohort such that the total number of patients in the non-ADHD cohort is 3 times that of the ADHD cohort to account for large differences in sample size
As of index date, the ADHD cohort was younger than the non-ADHD cohort (mean age: 35.2 and 44.0 years; std. diff. = 0.68). In both cohorts, slightly over half of the patients were female (54.5% and 52.4%; std. diff. = 0.04), and the South was the most represented region (48.7% and 42.5%; std. diff. = 0.13).
During the baseline period, the most frequent physical comorbidities in the ADHD and non-ADHD cohorts were hypertension (12.4% and 21.3%; std. diff. = 0.24), obesity (10.0% and 9.4%; std. diff. = 0.02), and chronic pulmonary disease (9.0% and 7.2%; std. diff. = 0.07).
A lower proportion of patients had no mental health comorbidities in the ADHD cohort than the non-ADHD cohort (42.0% and 70.8%; std. diff. = 0.61). The mean ± SD number of mental health comorbidities was 1.2 ± 1.4 in the ADHD cohort and 0.5 ± 0.9 in the non-ADHD cohort (std. diff. = 0.65). The most frequent mental health comorbidities in the ADHD and non-ADHD cohorts were anxiety disorders (34.4% and 11.1%; std. diff. = 0.58), depressive disorders (27.9% and 7.8%; std. diff. = 0.54), sleep-wake disorders (13.2% and 7.7%; std. diff. = 0.18), trauma- and stressor-related disorders (12.4% and 3.4%; std. diff. = 0.34), and substance-related and addictive disorders (9.4% and 5.0%; std. diff. = 0.17).
A higher proportion of patients in the ADHD than the non-ADHD cohort received antidepressants (40.9% and 15.8%; std. diff. = 0.58), antianxiety agents (20.6% and 8.3%; std. diff. = 0.36), anticonvulsants (16.1% and 6.8%; std. diff. = 0.29), and antipsychotics (7.2% and 1.5%; std. diff. = 0.28).
Healthcare resource utilization
The ADHD cohort, relative to the non-ADHD cohort, had generally higher mean ± SD rates of healthcare resource utilization, including more psychotherapy visits (2.9 ± 8.8 and 0.6 ± 4.0; std. diff. = 0.34), emergency room visits (0.6 ± 1.7 and 0.4 ± 1.2; std. diff. = 0.14), outpatient visits (12.7 ± 16.5 and 8.3 ± 12.4; std. diff. = 0.30), and specialist visits (1.0 ± 4.0 and 0.2 ± 1.8; std. diff. = 0.24); the number of inpatient visits were similar between cohorts (0.1 ± 0.4 and 0.1 ± 0.3; std. diff. = 0.04).
Association between risk factors and ADHD diagnosis
The risk factors with a significant association with an ADHD diagnosis are presented in Fig. 2 . Demographically, being younger and living in the South were risk factors for having an ADHD diagnosis (OR for age: 0.95; OR for region of residence using South as a reference: Midwest, 0.79; West, 0.70; Northwest, 0.67; all p < 0.05).
ADHD, attention-deficit/hyperactivity disorder; CI, confidence interval; OR, odds ratio
*Statistically significant at the 5% level
1 Estimated from logistic regression analyses
Other key risk factors associated with a significantly increased probability of having an ADHD diagnosis included the number of mental health comorbidities (OR for 1 comorbidity: 1.41; ≥2 comorbidities: 1.45); certain mental health comorbidities, including feeding and eating disorders (OR: 1.88), bipolar disorders (OR: 1.50), depressive disorders (OR: 1.37), trauma- and stressor-related disorders (OR: 1.27), anxiety disorders (OR: 1.24), sleep-wake disorders (OR: 1.23), and obsessive compulsive disorders (OR: 1.22); use of antidepressants (OR: 1.87) and antianxiety agents (OR: 1.40); and having ≥ 1 psychotherapy visit (OR: 1.70), ≥ 1 specialist visit (OR: 1.30), and ≥ 10 outpatient visits (OR: 1.51) (all p < 0.05).
Predicted risk of ADHD for patient profiles with selected risk factors
Selected risk factors identified from the logistic regression analyses were used to create fictitious common patient profiles to demonstrate their combined impact on the predicted risk of having an ADHD diagnosis (Fig. 3 ). Five of the six profiles correspond to patients with the same demographic characteristics (i.e., aged 35 years and living in the South) but vary in terms of the number (i.e., 1 or ≥ 2) and types of mental health comorbidities (i.e., anxiety disorder and/or depressive disorder), the pharmacological treatment received (i.e., antianxiety and/or antidepressant agent, or no treatment), and the level of healthcare resource utilization (i.e., number of psychotherapy, specialist, and outpatient visits). The remaining profile corresponds to low-risk patients with no relevant risk factors for ADHD.
Predicted risk of ADHD for selected patient profiles
ADHD, attention-deficit/hyperactivity disorder
Based on these patient profiles, the predicted risk of ADHD was the highest among patients with treated anxiety and depressive disorders (profile 3). More specifically, a patient presenting with the characteristics described in this profile would have an 81.9% likelihood of being diagnosed with ADHD in the coming year. The profile with the next highest predicted risk of ADHD was patients with treated depressive disorder (profile 2; 71.7%), followed by patients with treated anxiety disorder (profile 1; 63.4%). Profiles corresponding to a moderate predicted risk of ADHD included patients with untreated anxiety and depressive disorders (profile 4; 38.9%) and patients with sleep-wake disorder (profile 5; 34.5%). The predicted risk for ADHD among low-risk patients (profile 6) was 1.5%.
This large retrospective case-control study has identified a broad range of risk factors associated with ADHD in adults and quantified the added likelihood of an ADHD diagnosis contributed by each factor. Certain mental health comorbidities and their associated treatments and care were found to be significantly associated with newly diagnosed ADHD in adults. Specifically, the presence of common mental health comorbidities of ADHD such as anxiety and depressive disorders was associated with 24% and 37% increased risk of having an ADHD diagnosis, respectively. The use of pharmacological treatments for these conditions such as antianxiety agents and antidepressants was associated with an increased risk of having an ADHD diagnosis of 40% and 87%, respectively; having at least one prior psychotherapy visit was also associated with a 70% increased risk. Demographically, being younger and living in the South were found to be risk factors for having an ADHD diagnosis. The combined impact of selected risk factors on the predicted ADHD risk was explored through specific patient profiles, which demonstrated how the findings may be interpreted in clinical settings. The presence of a combination of risk factors may suggest that a patient is at a high risk of having undiagnosed ADHD and signify the need for further assessments. Collectively, findings of this study have extended our understanding on the patient path to ADHD diagnosis as well as the characteristics and clinical events that could suggest undiagnosed ADHD in adults.
Most prior studies examining characteristics associated with ADHD have focused on a single or a few factors, and many were conducted in pediatric populations [ 18 , 19 , 20 , 21 , 22 , 23 ]. Nonetheless, the risk factors for ADHD identified in the current study are largely aligned with the literature. For instance, among prior research in adults, a multicenter patient register study found that at the time of first ADHD diagnosis, mental health comorbidities were present in two-thirds of the patients; patients on average presented with 2.4 comorbidities, with the most common comorbidities being substance use disorders, anxiety disorders, mood disorders, and personality disorders [ 6 ]. Another study among adult members of two large managed healthcare plans found that compared with individuals without ADHD, those screened positive for ADHD through a telephone survey but had no documented ADHD diagnosis (i.e., the undiagnosed group) had significantly higher rates of mental health comorbidities (e.g., anxiety, depression, bipolar disorder) and were more likely to receive medications for a mental health condition [ 25 ]. In line with these findings, the current exploratory patient profile analyses also suggest that patients with more mental health comorbidities and have received the associated pharmacological treatments and care are at a higher risk of having undiagnosed ADHD than those with fewer or untreated mental health comorbidities.
The current study also found that an overall higher healthcare resource utilization was a characteristic associated with newly diagnosed ADHD among adult patients. A potential interpretation of this finding is that an individual who experienced ADHD-related symptoms might visit a psychologist or physician frequently to seek help for the symptoms; thus, a high level of prior healthcare resource utilization may be a sign that an individual could have undiagnosed ADHD. Clinical judgement should be applied to determine whether further evaluation for ADHD is needed on a case-by-case basis considering the presence of other high-risk characteristics.
The diagnosis of ADHD can be challenging, particularly among adults [ 2 , 3 ]. The current study suggests that information on patient characteristics, such as the presence of mental health comorbidities and healthcare resource utilization history, may be used to aid clinicians identify adult patients at risk of ADHD and minimize missed opportunity to provide a timely diagnosis of ADHD and the proper care. Notably, underdiagnosis or a delayed diagnosis of ADHD leads to undertreatment and can adversely affect patients’ occupational achievements, diminish self-esteem, and hamper interpersonal relationships, considerably reducing the quality of life [ 8 ]. ADHD in adults has also been shown to be associated with approximately $123 billion total societal excess costs in the US [ 26 ]. Consequently, early detection and treatment of ADHD may have the potential to alleviate the large patient and societal burden associated with the condition.
It is worth mentioning that causes for ADHD is multifactorial, and multiple risk factors may contribute to the risk of having ADHD [ 15 ]. Some risk factors in the literature (e.g., genetics and environmental factors [ 27 , 28 ]) are not available in claims data, and these factors are important to consider when establishing an ADHD diagnosis. Nonetheless, the risk factors identified in this study were generated based on a large sample size (over 1.3 million adults), and as exemplified by the exploratory patient profiles, the presence of multiple risk factors was associated with an overall higher risk of having undiagnosed ADHD. Together, these findings would help inform clinicians on the types of high-risk patient profiles that should raise a red flag for potential ADHD and prompt further clinical assessments, such as family psychiatric history and diagnostic interviews. As such, findings of this study may facilitate early diagnosis and appropriate management of ADHD among adults, which may in turn improve patient outcomes.
The findings of the current study should be considered in light of certain limitations inherent to retrospective databases using claims data, including the risk of data omissions, coding errors, and the presence of rule-out diagnosis. Nonetheless, while few studies specifically assessed the validity of ICD-10-CM codes for ADHD diagnoses in claims data, literature evidence has suggested high accuracy of ICD-9-CM codes in identifying neurodevelopmental disorders, including ADHD, and a good correspondence between the ICD-9 and − 10 codes is expected [ 29 , 30 ]. Furthermore, ICD codes have been widely used in the literature to identify ADHD diagnoses in claims-based analyses [ 31 , 32 , 33 ]. Meanwhile, as the study included commercially insured patients, the sample may not be representative of the entire ADHD population in the US. Furthermore, potential risk factors were limited to information available in health insurance claims data only, which may lack relevant information related to ADHD, such as presence of childhood ADHD, family history, or environmental factors. In addition, some characteristics may interact with multiple variables such that their association with an ADHD diagnosis may already be captured by other variables; as such, a characteristic with an OR of less than 1 should not be interpreted as having a protective effect against an ADHD diagnosis but rather that the characteristic alone may be insufficient to prompt screening for ADHD. Lastly, findings from this retrospective observational analysis should be interpreted as measures of association; no causal inference can be drawn.
This large retrospective case-control study found that mental health comorbidities and related treatments and care are significantly associated with newly diagnosed ADHD in US adults. The presence of a combination of risk factors may suggest that a patient is at a high risk of having undiagnosed ADHD. The results of this study provide insights on the path to ADHD diagnosis and may aid clinicians identify at-risk patients for screening, which may facilitate early diagnosis and appropriate management of ADHD.
The data that support the findings of this study are available from IQVIA but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the corresponding author (email: [email protected]) upon reasonable request and with permission of IQVIA.
- Attention-deficit/hyperactivity disorder
Health Insurance Portability and Accountability Act
International Classification of Diseases, Tenth Revision, Clinical Modification
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Medical writing assistance was provided by Flora Chik, PhD, MWC, an employee of Analysis Group, Inc., and funded by Otsuka Pharmaceutical Development & Commercialization, Inc.
Financial support for this research was provided by Otsuka Pharmaceutical Development & Commercialization, Inc. The study sponsor was involved in several aspects of the research, including the study design, the interpretation of data, the writing of the manuscript, and the decision to submit the manuscript for publication.
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Martin Cloutier, Marjolaine Gauthier-Loiselle, Rebecca Bungay, Emmanuelle Arpin & Annie Guerin
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MC, MGL, RB, EA, and AG contributed to study conception and design, collection and assembly of data, and data analysis and interpretation. JS and AC contributed to study conception and design, data analysis and interpretation. All authors reviewed and approved the final content of this manuscript.
Correspondence to Rebecca Bungay .
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The research was conducted according to the principles of the Declaration of Helsinki. Data analyzed in this study are de-identified and comply with the patient requirements of the Health Insurance Portability and Accountability Act (HIPAA); therefore, no review by an institutional review board nor informed consent was required per Title 45 of CFR, Part 46.101(b)(4) [ 24 ].
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JS is an employee of Otsuka Pharmaceutical Development & Commercialization, Inc. AC received research support from Allergan, Takeda/Shire, Emalex, Akili, Ironshore, Arbor, Aevi Genomic Medicine, Neos Therapeutics, Otsuka, Pfizer, Purdue, Rhodes, Sunovion, Tris, KemPharm, Supernus, and the U.S. Food and Drug Administration; was on the advisory board of Takeda/Shire, Akili, Arbor, Cingulate, Ironshore, Neos Therapeutics, Otsuka, Pfizer, Purdue, Adlon, Rhodes, Sunovion, Tris, Supernus, and Corium; received consulting fees from Arbor, Ironshore, Neos Therapeutics, Purdue, Rhodes, Sunovion, Tris, KemPharm, Supernus, Corium, Jazz, Tulex Pharma, and Lumos Pharma; received speaker fees from Takeda/Shire, Arbor, Ironshore, Neos Therapeutics, Pfizer, Tris, and Supernus; and received writing support from Takeda /Shire, Arbor, Ironshore, Neos Therapeutics, Pfizer, Purdue, Rhodes, Sunovion, and Tris. MC, MGL, RB, EA, and AG are employees of Analysis Group, Inc., a consulting company that has provided paid consulting services to Otsuka Pharmaceutical Development & Commercialization, Inc.
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Schein, J., Cloutier, M., Gauthier-Loiselle, M. et al. Risk factors associated with newly diagnosed attention-deficit/hyperactivity disorder in adults: a retrospective case-control study. BMC Psychiatry 23 , 870 (2023). https://doi.org/10.1186/s12888-023-05359-7
Received : 05 May 2023
Accepted : 07 November 2023
Published : 23 November 2023
DOI : https://doi.org/10.1186/s12888-023-05359-7
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Case Studies in Clinical Psychological Science: Bridging the Gap from Science to Practice
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Case Studies in Clinical Psychological Science demonstrates in detail how the clinical science model can be applied to actual cases. It presents dialogues between leading clinical researchers regarding the treatment of a wide variety of psychological problems, from depression and Alzheimer's disease to Panic Disorder and chronic pain. Chapters describe what evidence-based practice consists of for various clinical problems and are followed by commentary sections in which other leading clinical researchers analyze the case at hand, pointing out additional assessment and treatment options and controversial issues. It examines the application of scientifically based interventions to actual cases and models thoughtful and collegial discussion among prominent clinical researchers
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Postpartum and non-postpartum depression: a population-based matched case-control study comparing polygenic risk scores for severe mental disorders
- 1 NCRR-The National Centre for Register-based Research, Aarhus University, Aarhus, Denmark.
- 2 iPSYCH-Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus, Denmark.
- 3 Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
- 4 MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, UK.
- 5 Department of Psychiatry, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands.
- 6 Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York City, NY, USA.
- 7 Department of Neurology and Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Denmark.
- 8 CIRRAU-Centre for Integrated Register-based Research, Aarhus University, Aarhus, Denmark.
- 9 Institute of Biological Psychiatry, Mental Health Center Sct. Hans, Mental Health Services Capital Region of Denmark, Copenhagen, Denmark.
- 10 Institute of Clinical Medicine, Faculty of Health Science, University of Copenhagen, Copenhagen, Denmark.
- 11 CORE- Copenhagen Research Centre for Mental Health, Mental Health Centre Copenhagen, Mental Health Services in the Capital Region of Denmark, Copenhagen, Denmark.
- 12 Department for Congenital Disorders, Statens Serum Institut, Copenhagen, Denmark.
- 13 Department of Biomedicine, Aarhus University, Aarhus, Denmark.
- 14 Center for Genomics and Personalized Medicine, CGPM, Aarhus University, Aarhus, Denmark.
- 15 Psychosis Research Unit, Aarhus University Hospital-Psychiatry, Risskov, Denmark.
- 16 NCRR-The National Centre for Register-based Research, Aarhus University, Aarhus, Denmark. [email protected].
- 17 iPSYCH-Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus, Denmark. [email protected].
- PMID: 37953300
- PMCID: PMC10641081
- DOI: 10.1038/s41398-023-02649-2
It remains inconclusive whether postpartum depression (PPD) and depression with onset outside the postpartum period (MDD) are genetically distinct disorders. We aimed to investigate whether polygenic risk scores (PGSs) for major mental disorders differ between PPD cases and MDD cases in a nested case-control study of 50,057 women born from 1981 to 1997 in the iPSYCH2015 sample in Demark. We identified 333 women with first-onset postpartum depression (PPD group), who were matched with 993 women with first-onset depression diagnosed outside of postpartum (MDD group), and 999 female population controls. Data on genetics and depressive disorders were retrieved from neonatal biobanks and the Psychiatric Central Research Register. PGSs were calculated from both individual-level genetic data and meta-analysis summary statistics from the Psychiatric Genomics Consortium. Conditional logistic regression was used to calculate the odds ratio (OR), accounting for the selection-related reproductive behavior. After adjustment for covariates, higher PGSs for severe mental disorders were associated with increased ORs of both PPD and MDD. Compared with MDD cases, MDD PGS and attention-deficit/hyperactivity disorder PGS were marginally but not statistically higher for PPD cases, with the OR of PPD versus MDD being 1.12 (95% CI: 0 .97-1.29) and 1.11 (0.97-1.27) per-standard deviation increase, respectively. The ORs of PPD versus MDD did not statistically differ by PGSs of bipolar disorder, schizophrenia, or autism spectrum disorder. Our findings suggest that relying on PGS data, there was no clear evidence of distinct genetic make-up of women with depression occurring during or outside postpartum, after taking the selection-related reproductive behavior into account.
© 2023. The Author(s).
- Autism Spectrum Disorder*
- Case-Control Studies
- Depression, Postpartum* / epidemiology
- Depression, Postpartum* / genetics
- Depressive Disorder, Major* / diagnosis
- Infant, Newborn
- Postpartum Period / psychology
- Risk Factors
Grants and funding
- R01 MH122869/MH/NIMH NIH HHS/United States
- Open access
- Published: 14 November 2023
Experiences of living with binge eating disorder and facilitators of recovery processes: a qualitative study
- Marit Fjerdingren Bremer 1 ,
- Lisa Garnweidner-Holme 2 ,
- Linda Nesse 1 , 3 &
- Marianne Molin 2 , 4
Journal of Eating Disorders volume 11 , Article number: 201 ( 2023 ) Cite this article
Binge eating disorder (BED) is the most prevalent eating disorder worldwide. BED is often associated with low quality of life and mental health problems. Given the complexity of the disorder, recovery may be challenging. Since BED was only recently specified as a diagnostic category by the World Health Organization (2021), little is known about how patients experience living with BED in everyday life. This study aimed to explore how patients experience living with BED and to investigate factors perceived as facilitating recovery.
Individual interviews were conducted with six patients in a rehabilitation programme for recovery from BED. Interviews were conducted digitally and verbally transcribed between December 2020 and January 2021. The analysis was based on Malterud’s systematic text condensation.
Being diagnosed with BED could be experienced as a relief. The participants perceived living with BED as a challenging addiction. They struggled with a low self-image and experienced a lack of understanding from others, resulting in shame. Self-compassion and social support from friends and family and through participation in a rehabilitation programme were important facilitators of recovery.
Participants perceived living with BED as a challenging addiction. They struggled with low self-esteem and experienced a lack of understanding from others, resulting in shame. Being diagnosed with BED was perceived as a relief. They appreciated that issues related to mental health were addressed during rehabilitation to better understand the complexity of BED. Knowledge about BED, as well as the difficulties of living with BED among family members and friends might help patients with BED feel less ashamed of their disorder and could thus contribute to increased self-compassion.
Plain English summary
We interviewed six patients with binge eating disorder (BED) about their experiences living with BED, which is the most prevalent eating disorder worldwide. However, difficulties diagnosing patients with BED and a lack of knowledge about BED among healthcare professionals make it challenging to provide patients with appropriate help to recover from BED. The participants in our study participated in a rehabilitation programme for BED. They experienced living with BED as a challenging addiction. Low self-image and others’ lack of understanding made the individuals ashamed of their eating disorders. Self-compassion and social support through taking part in the rehabilitation programme were important facilitators of recovery. This study indicates that more knowledge about BED among family members, friends and healthcare professionals and social support are notable facilitators for recovering from BED.
Even though BED is the most prevalent eating disorder, we have limited knowledge about how patients experience living with BED and their recovery processes
Patients with BED described the disorder as a challenging addiction
Low self-image and lack of understanding by others made the participants ashamed of their disordered eating behaviours
Self-compassion and social support were perceived as core facilitators of recovery
The key characteristics of binge eating disorder (BED) are the tendency to engage in binge eating episodes during which excessive amounts of food are consumed in a short period of time, paired with a subjective sense of loss of control [ 1 ]. BED was first recognised as a diagnostic category in the fifth version of the American Diagnostic and Statistical Model of Mental Disorders (DSM) in 2013 [ 2 ]. In the European System’s International Classification of Diseases, BED was first specified in 2018 [ 3 ]. The lifetime prevalence of BED is estimated to between 1.5 and 1.9%, making it the most prevalent of the eating disorders [ 4 , 5 ]. Although BED is considered the most common eating disorder, it can be argued to be the eating disorder that receives the least attention in mental health care. Several models of environmental factors contributing to BED have been proposed [ 6 ]. These for instance include media exposure, thin-ideal internalisation, and personality traits such as negative emotionality [ 6 ]. People with overweight or obesity appear to be at particular risk of developing BED although the directionality in the relationship between overweight, obesity and BED is complex and unclear [ 7 ].
Recovery from eating disorders is a non-linear process that includes psychological and social changes, including experiences of empowerment, relationships with others, as well as improvements in body image and reductions in disordered eating patterns [ 8 ]. Given the complexity of BED, recovery can be a challenging process [ 9 ]. Recovery rates, on average, remain below 50% and largely depend on how recovery is defined [ 10 ]. Recovery from BED may be understood and defined differently by patients and health professionals [ 10 ].
There is an increasing awareness of BED in the research literature on eating disorders, with several studies exploring patients’ positive and negative experiences of participation in treatment and rehabilitation [ 11 , 12 , 13 , 14 ]. However, there appears to be fewer studies on patients’ experiences of living with BED in everyday life [ 15 , 16 , 17 , 18 , 19 ]. In qualitative studies, patients have described living with BED as characterized by experiences of guilt and shame, as well as a loss of control [ 15 , 16 , 17 , 18 , 19 ]. However, accepting the disorder and being validated by others have been described as important steps in the recovery process [ 17 ]. Furthermore, psychotherapy and person-centred treatment may facilitate recovery [ 15 , 16 , 17 ]. Although some studies have investigated patients’ experiences with recovery from BED [ 8 , 17 , 20 , 21 ], we have limited in-depth knowledge on facilitators of recovery. Knowledge about how patients experience living with and recovering from BED may be important for better informing our understanding of the influence of BED on everyday life and for tailoring treatment to best promote recovery [ 22 ]. This study explores how persons with BED experience living with this eating disorder and investigates factors that were perceived as facilitating recovery.
Design and data collection
Semi-structured individual interviews were conducted by MFB between December 2020 and January 2021. MFB holds a master’s degree in public health science and a bachelor’s degree in public nutrition. MFB currently works at a rehabilitation centre as a nutritionist with patients with obesity. The individuals in this study were recruited from another rehabilitation centre and MFB did not have former knowledge to the participants. Due to the COVID-19 pandemic, the interviews took place online using a digital platform called Visiba Care (visibacare.com), an application or web interface that offers secure communication through video. The interview guide (Additional file 1 ) was developed by MFB, LN and MM. LN is a clinical psychologist with a PhD in public health science who works in addiction research. MM holds a PhD in nutrition and is a professor in public health and public health nutrition. The themes in the interview guide were developed inductively guided by the research questions of the investigators. The interview guide was pilot tested with a patient with BED. The pilot interview did not change the interview guide. Hence, the pilot interview was included in the sample and analysis of this article. 11 participants attending the rehabilitation programme were invited to participate in the study. 6 agreed to participate. We did not include more participants because we reached information power [ 23 ], due to these 6 informants provided very relevant information for the actual research questions in the study. Before participation, the interviewees gave their written informed consent. Recruitment continued until we reached informational power related to the richness of the data [ 23 ]. Interviews were audio-recorded with a Dictaphone application [ 24 ] and lasted 45–60 min. The interviews were transcribed verbatim by MFB. All the authors read the transcribed interviews. The study was conducted in accordance with COREQ guidelines [ 25 ].
Participants and setting
The participants were all women between 30 and 70 years old. In Norway, persons who have a Body Mass Index (BMI) > 40 without comorbidities or a BMI > 35 with comorbidities qualify for treatment at rehabilitation centres [ 26 ]. In some of these centres, patients are screened for eating disorders to identify the potential coexistence of BED. Participants in this study were in treatment for obesity at one of these rehabilitation centres. Based on screening procedures after entering rehabilitation, patients who experienced co-occurring challenges with binge eating were offered participation in a rehabilitation programme focusing on coping with and recovering from BED. The screening process consisted of six questionnaires and a consultation with a psychologist. A clinical assessment was made of whether the person met BED criteria. The questionnaires explored the patients’ eating behaviours and thoughts and feelings related to food. Two questionnaires mapped the patients’ mental health, including anxiety and depressive symptoms.
As part of the rehabilitation programme, sessions were held once a week over three months. The programme involved individual and group-based sessions, with 10 participants, about behaviour change, physical activity, diet, mental health, motivation and empowerment. The group-based sessions were led by a specialist in clinical psychology and a clinical nutritionist. The group-based sessions focused on challenges with binge eating, and important parts of the group discussions were self-esteem, causes and triggers of binging, knowledge of physiological mechanisms, understanding of thoughts and emotions’ influence on behaviours, and further work on recovery. Respondents were given fictive names in the presentation of the results to secure their privacy.
The analysis was conducted by MFB and was guided by Malterud’s systematic text condensation [ 27 ], a descriptive and explorative method inspired by phenomenology. LGH, LN and MM assisted with the analysis. The analysis involved the following steps: (1) reading all the transcribed interviews to obtain an overall impression and rereading them with a focus on the study’s aim; (2) identifying and sorting meaning units representing aspects of participants’ lived experiences with BED and perceived facilitators for recovery and coding; (3) condensing the contents and meanings of each coded group and (4) synthesising the contents of each code group to generalise descriptions and concepts. The process to formulate meaning units and the subsequent coding of the content and meaning involved discussion and clearance of the text. The main focus was to discuss understanding of the text, compare main impressions and themes, which again could provide an overview of similarities and differences. We highlighted recurring citations and citations that gave information on equal topics.
We identified the following two main themes related to patients’ experiences with BED (Fig. 1 ): (1) A challenging addiction with the subthemes giving it a name , living in a negative spiral and it’s in your head ; and (2) shame with the subthemes painful thoughts and feelings , negative self-image and feeling misunderstood . We found three main themes regarding the perceived facilitators of recovery: (1) recovery is a long process with the subthemes acceptance of the disorder and give yourself time ; (2) coping with the subthemes self-compassion and strategies to manage the disorder ; (3) community with the subthemes group affiliation and social support .
Main themes and subthemes concerning the experience of living with BED
Experiences of living with BED
The participants described living with BED as a challenging addiction . Berit explained how difficult it was to stop eating: ‘When I eat, I get happy right there and then, but when I think about it, and the dopamine or whatever it is stops working, I feel completely unsuccessful, and then I think that I can just give up. It is over. I just continue to eat. … I can’t do anything right anyway’.
Giving it a name describes participants’ experienced relief of being diagnosed with BED. The participants experienced BED as a complex condition and a challenging disorder that removed their focus from other notable areas of life. They often told stories of repeated feelings of failure in their management of BED. They felt too embarrassed to tell anyone in their lives about their diagnoses and, thus, kept it a secret, even though they thought their family members already probably knew. Their frustration with not being able to control their eating was described as confusing and time consuming. They felt hopeless and stupid. However, being diagnosed with BED was often described as a relief, which Nora expressed:
‘It’s actually been really nice. (...) I was referred because of my overweight, uhh, and based on mapping and such, I was diagnosed with binge eating disorder. And I was about to say, uhh, that I wasn’t completely surprised. I’ve realised in a way that there has been a problem, uhh, but at the same time, it was kind of good to have it confirmed (...)’.
All participants were diagnosed with BED at the rehabilitation centre.
The participants described living with BED as a negative spiral that was difficult to escape and characterised by periods of guilt when they could not control their eating habits. Tuva explained, ‘Yes, it’s like I don’t use my head. I don’t do what I’m supposed to, ehh, and I don’t enjoy it. I sit and eat with a guilty conscience’. Conversely, the participants stated that binging gave them good feelings and satisfaction. These binge eating episodes were considered a reward or a strategy to escape stressful experiences in daily life.
Dealing with binge eating was often viewed in the context of how they otherwise felt in life. A negative spiral was also mentioned concerning weight management experiences. Individuals had experiences in which they lost weight but had trouble maintaining weight loss. This led to dissatisfaction and hopelessness and resulted in episodes of increased binge eating. Some participants had lived with BED for a long time and had experienced BED as a permanent part of them.
Participants experienced BED as something that is in your head , as Pia expressed: ‘At least it starts there, that the body is a symptom of what’s in the head. I think that about my suffering, that the physical kind of reflects the mental’. It was vital for participants to understand the connection between physical and mental challenges and how these affect each other. Negative thoughts and feelings often led to binge eating episodes, and subjects appreciated the focus on mental health in the rehabilitation centre to learn strategies to cope and choose differently.
All participants associated BED with shame , as illustrated by Berit’s statement:
‘It is very taboo, very taboo. I try to hide it from everyone. When we’re with others, I don’t eat more than others, but when I’m at home and no one sees me, that’s when I eat. So, it’s tiring, and you always watch out. You never feel well enough, and uhh yeah, it really hurts’. Shame was often described as painful feelings and negative thoughts . The participants often felt ashamed when other people asked them, ‘Why can’t you just stop eating?’ This question made them feel ashamed of not being in control of their eating behaviours. In this context, the respondents explained that most binge eating episodes occurred when they were alone to avoid feelings of shame. The participants had many negative thoughts and spent much time ruminating about what others thought about them. Thus, shame often related to subjects’ negative self-image , as this comment by Pia illustrated: ‘That’s kind of what the body ideals are today, thin and slim, and if you don’t fit in that category, there’s something wrong with you’.
Several participants described having a negative self-image and critical thoughts about their bodies and behaviours. They mentioned that they already had negative self-images before developing obesity and being diagnosed with BED. Obesity was considered challenging in terms of physical limitations and mental health struggles. They described feelings of not fitting into the bodily ideals in today’s society, where thinness and health are expected.
Living with shame was also connected to a feeling of being misunderstood by family members, friends or even health professionals. Berit stated: ‘I had a doctor who said, “You just have to pull yourself together. You just have to eat right”. I think there are probably a lot of doctors who don’t have knowledge about binge eating’.
Participants experienced little openness about BED. They expressed that they feel it is more common to talk and hear about anorexia and bulimia. Having a less-known eating disorder makes it harder to be open and honest. Some kept the disorder a secret from family and friends, which again worsened their shame and hopelessness.
Facilitators of recovery processes
Recovery from BED was often considered a long process involving accepting the disorder and giving oneself time . Participants defined ‘recovery’ as the process of reducing binge eating and enhancing coping. Being healthy did not imply the total absence of binge eating episodes, but having greater control over the occurrence and amount of food consumed during binge eating episodes, as Kari explained: ‘It is about coping with it so that it does not happen so often and regularly, but to accept that it can happen once in a while and that it is normal and that you should not feel that you have failed. Because I think that when it happens once, seldom, that I have succeeded in recovering’. The participants did not perceive recovery from BED as being healthy, since they often had other diseases that they had to handle, such as diabetes.
They perceived it as important to have strategies to manage recovery, as Pia described: ‘ I think that you have to work on it continuously. But I see a change because I have gotten some tools that I can use in such situations, and I have another mindset now. I feel more relaxed’.
Managing to cope with recurring binge eating episodes was considered an important facilitator of recovery. Participants associated coping with exerting control over their eating behaviours. Many subjects felt more in control with others but felt they could lose it when they were alone, as Silje explained: ‘It’s kind of like how you compare yourself to others and how they manage to control their eating, uhh, and that's what I want, too’.
The participants often managed to have control by avoiding access to foods that triggered BED (e.g. sweets). Nora said, ‘I have the knowledge to choose the food that’s right for me, and I need to have it available’ . Furthermore, they related coping to ‘inner factors’ that influence their health and quality of life. For instance, focusing on health aspects was considered more important than focusing on weight. Health aspects were also an important motivation for recovery. Several participants explained that pain due to being overweight, such as knee arthrosis, motivated them to control their BED.
In addition, self-compassion was often mentioned as a significant facilitator of recovery. Participants gave themselves credit and bragged about periods without binge eating as positively self-reinforcing, often disrupting their negative spirals. Pia explained, ‘Self-compassion is very important for me, hm, being good with myself, being my own best friend and to think about what is good for me. Like, ‘Are episodes with binge eating good for me? No, they are not. It is better for me to go for a walk or to eat fruit’. However, the participants said that self-compassion requires awareness and practice. They highlighted getting older, gaining life experience and being more mature and reflective as factors that made it easier to give oneself acceptance.
‘Time outs’ from eating were reported as an important strategy to manage the disorder . The patients stated that breaks gave them time to reflect on why they were eating, as Berit explained: ‘It has also helped me to wait for 15 min and to eat what you like. Take a 15-min break to see if I really want to eat. Very often, you actually don’t want to. I may start to eat, but then I am at least more aware of eating.’ Another participant stated that it was important not to be too strict with oneself and not to have overly strict rules, such as ‘yes food’ and ‘no food’, to cope with BED. Good eating routines were another factor that facilitated recovery. Outdoor activities, listening to music, reading books, knitting and talking to oneself often helped interviewees to avoid new BED episodes. They appreciated that the present rehabilitation programme focused on mental health, well-being and personal relationships with food. Learning about BED gave them a better understanding that obesity did not just result from a lack of self-control and willpower.
One of the most significant facilitators for managing recovery was a community characterised by group affiliation and social support . All outlined the importance of the community at the rehabilitation centre, as Pia described: ‘It was very good to meet others in the same situation and to get validation that there are more people in the same situation and that you can talk to them openly about these episodes without being judged’.
Some participants feared how they would cope with BED once they no longer belonged to a rehabilitation programme. The perceived social support of others in the group gave them safety. Nora explained, ‘It was very good to not feel alone (…) to hear that others have the same problems. This made it easier to share my experiences. Being together with others in the same situation makes me feel safe’. The subjects learned to share BED-related experiences and feelings in the group. For recovery, they also considered it important to learn to share their feelings with others outside the programme, as Nora said: ‘I have been better about talking about my feelings at home, for example “Now I am alone, and I am sad because you are not here”’.
The participants in this study perceived living with BED as a challenging addiction. Being diagnosed with BED could be a relief; however, a negative self-image and experiencing a lack of understanding from others made the participants ashamed of their disorder. The participants experienced limited openness about BED and mental disorders in their social surroundings. Even though participants were still living with BED, perceived facilitators of recovery were self-compassion and social support received during rehabilitation.
In a study comparing how obese women with and without BED experienced binge eating [ 28 ], the authors found that women experienced BED as a form of addiction. In this context, the participants in our study experienced living with BED as characterised by negative thoughts and feelings. A review of research on emotion regulation in BED found that negative emotions play an important role in the onset and maintenance of binge eating [ 29 ]. Likewise, the participants in our study perceived living with BED as a rollercoaster ride of emotions, where the distance between positive and negative feelings was short. Experiences of living with BED as a negative spiral was also described in another study of patients with BED in the US [ 14 ].
The participants in our study often experienced living with BED as characterized by the shame of not having control over their eating habits and weight. Negative comments from family members or friends about their eating habits or obesity exacerbated shame. The participants also related shame to feeling misunderstood by family members, friends or even health professionals. This finding corroborates studies that found that patients with BED often felt misunderstood by health professionals [ 8 ]. There are indications that health professionals have limited knowledge of BED. A cross-sectional study in the US identified low awareness of and knowledge about BED among health professionals.
Shame of not having control was identified as hindering recovery in other studies [ 17 , 29 , 30 ]. For instance, a qualitative study investigating using online messages in a rehabilitation programme for BED found that self-blame promoted a feedback cycle of binging, which was perceived as barrier for recovery [ 17 ]. As mentioned in the background, some studies have investigated patients’ experiences with recovery from BED [ 8 , 17 , 20 , 21 ]. Our participants experienced recovery as a long process that mainly concerned coping. Interestingly, recovery did not imply being fully recovered from binge eating episodes but rather control over the disorder. We found that self-compassion and social support within a rehabilitation programme were the most important facilitators for recovery. Self-compassion involves developing an accepting relationship with oneself, particularly in instances of perceived failure, inadequacy and personal suffering [ 31 ], while social support constitutes the availability of potential supporters, or structural support, and the perception of support, or functional support [ 32 ]. Studies have revealed promising results for compassion-focused therapy for recovery from BED [ 33 , 34 ]. Social support may play an important role in BED recovery process [ 32 , 35 , 36 ]. An Australian mixed-methods study outlined the social support in a Instagram community as important facilitator for recovery [ 37 ]. Similarly, social support was also a notable facilitator of group-based recovery for patients with BED, combining guided physical exercise and dietary therapy in a study from Norway [ 14 ]. Our participants outlined that for recovery, they considered it important to learn to share their feelings with others outside the programme.
All of our participants outlined the importance of being part in a rehabilitation programme for recovery from BED. Several studies have investigated participants’ experiences with different rehabilitation programmes for BED [ 12 , 14 , 17 , 37 ]. For instance, a qualitative study exploring participants’ experiences of a web-based programme for bulimia and BED found that interventions should be flexible, considering individual preferences [ 38 ]. The participants in our study described the value of addressing cognitive behavioural change and mental health and appreciated receiving support from an interprofessional team that collaborated in their recovery process. However, it should be acknowledged that all of the participants were overweight or obese before their diagnosis with BED. Their experiences with previous weight-loss programmes might have influenced their preferences for addressing mental health in rehabilitation. Women with BED in the US have also reported appreciating receiving weight-neutral rehabilitation programmes for BED after experiences of being blamed for their weight and health conditions [ 11 ]. Thus, rehabilitation programmes for patients with BED should be tailored towards subjectively relevant themes to facilitate recovery.
This study was conducted in a small sample size, which is usual for qualitative research aiming to investigate participants’ experiences [ 23 ]. However, it has to be acknowledged that the findings of this study are primarily applicable to the specific setting of the study and perhaps only transferable to patients in similar situations or rehabilitation programmes. Participants were interviewed a short time after they completed the programme. Hence, their responses might have been influenced by the focus of the content in programme in regard to facilitators for recovery. In addition, interviews were conducted digitally, which might have influenced the openness of the participants [ 39 ].
Conclusion and implications for practice
The participants perceived living with BED as a challenging addiction. They struggled with low self-esteem and experienced a lack of understanding from others, resulting in shame. They appreciated that issues related to mental health were addressed during rehabilitation to better understand the complexity of BED. Knowledge about BED as well as the difficulties of living with BED among family members and friends might help patients with BED feel less ashamed of their disorder and could thus contribute to increased self-compassion.Rehabilitation programmes should address social support in order to promote recovery from BED.
Availability of data and materials
The data analysis for this manuscript can be made available upon reasonable request by contacting the corresponding author.
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We thank the patients and the recruitment site for their participation in this study.
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Department of Public Health Science, Faculty of Landscape and Society, Norwegian University of Life Sciences, 1433, Ås, Norway
Marit Fjerdingren Bremer & Linda Nesse
Department of Nursing and Health Promotion, Faculty of Health Sciences, Oslo Metropolitan University, P.O. Box 4, St. Olavs Plass, 0130, Oslo, Norway
Lisa Garnweidner-Holme & Marianne Molin
SERAF, Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway
Department of Health and Exercise, Faculty of Health Sciences, Kristiania University College, Oslo, Norway
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MFB, LN and MM designed the research. MFB performed the analysis. MFB conducted the interviews. LN, MM and LGH assisted with the analysis. MFB and LGH drafted the manuscript. LN and MM critically reviewed and revised the manuscript. All the authors read and approved the final manuscript.
Correspondence to Lisa Garnweidner-Holme .
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The Norwegian Centre for Research Data (NSD, approval number 121485) approved the study. All subjects gave written informed consent according to the Declaration of Helsinki.
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Additional file 1.
. Interview guide.
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Bremer, M.F., Garnweidner-Holme, L., Nesse, L. et al. Experiences of living with binge eating disorder and facilitators of recovery processes: a qualitative study. J Eat Disord 11 , 201 (2023). https://doi.org/10.1186/s40337-023-00929-2
Received : 10 August 2023
Accepted : 10 November 2023
Published : 14 November 2023
DOI : https://doi.org/10.1186/s40337-023-00929-2
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“Considering everything, it seems we are dealing here with a special illness… There are certainly more psychiatric illnesses than are listed in our textbooks.” —Alois Alzheimer (In: Benjamin, 2018)
Once thought to be the product of demonic possession, immorality, or imbalanced humors, we now know that psychiatric symptoms are often caused by changes in the brain. Read on to learn about the people who helped us understand the brain as the driving force behind our behaviors.
In 1848, John Harlow first described the case of a 25-year-old railroad foreman named Phineas Gage. Gage was a "temperate" man: hardworking, polite, and well-liked by all those around him. One day, Gage was struck through the skull by an iron rod launched in an accidental explosion. The rod traveled through the prefrontal cortex of his brain. Remarkably, he survived with no deficits in his motor function or memory . However, his family and friends noticed major changes in his personality . He became impatient, unreliable, vulgar, and was even described as developing the "animal passions of a strong man." This was the first glimpse into the important role of the prefrontal cortex in personality and social behavior (David, 2009; Thiebaut de Schotten, 2015; Benjamin, 2018).
Louis Victor Leborgne
Pierre Broca first published the case of 50-year-old Louis Victor Leborgne in 1861. Despite normal intelligence , Leborgne inexplicably lost the ability to speak. His nickname was Tan, after this became the only word he ever uttered. He was otherwise unaffected and seemed to follow directions and understand others without difficulty. After he died, Broca examined his brain, finding an abnormal area of brain tissue only in the left anterior frontal lobe. This suggested that the left and right sides of the brain were not always symmetric in their functions, as previously thought. Broca later went on to describe several other similar cases, cementing the role of the left anterior frontal lobe (now called Broca’s area) as a crucial region for producing (but not understanding) language (Dronkers, 2007; David, 2009; Thiebaut de Schotten, 2015).
Psychiatrist and neuropathologist Aloysius Alzheimer described the case of Auguste Deter, a 56-year-old woman who passed away in 1906 after she developed strange behaviors, hallucinations, and memory loss. When Alzheimer looked at her brain under the microscope, he described amyloid plaques and neurofibrillary tangles that we now know are a hallmark of the disease that bears his name. This significant discovery was the first time that a biological molecule such as a protein was linked to a psychiatric illness (Shorter, 1997; David, 2009; Kalia & Costa e Silva, 2015).
In 1933, Spafford Ackerly described the case of "JP” who, beginning at a very young age, would do crude things like defecate on others' belongings, expose himself, and masturbate in front of other children at school. These behaviors worsened as he aged, leading to his arrest as a teenager . He was examined by Ackerly who found that the boy had a large cyst, likely present from birth, that caused severe damage to his prefrontal cortices. Like the case of Phineas Gage, JP helped us understand the crucial role that the prefrontal cortex plays in judgment, decision-making , social behaviors, and personality (Benjamin, 2018).
HM (Henry Gustav Molaison)
William Scoville first described the case of HM, a 29-year-old man whom he had treated two years earlier with an experimental surgery to remove his medial temporal lobes (including the hippocampus and amygdala on both sides). The hope was that the surgery would control his severe epilepsy, and it did seem to help. But with that improvement came a very unexpected side effect: HM completely lost the ability to form certain kinds of new memories. While he was still able to form new implicit or procedural memories (like tying shoes or playing the piano), he was no longer able to form new semantic or declarative memories (like someone’s name or major life events). This taught us that memories were localized to a specific brain region, not distributed throughout the whole brain as previously thought (David, 2009; Thiebaut de Schotten, 2015; Benjamin, 2018).
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Benjamin, S., MacGillivray, L., Schildkrout, B., Cohen-Oram, A., Lauterbach, M.D., & Levin, L.L. (2018). Six landmark case reports essential for neuropsychiatric literacy. J Neuropsychiatry Clin Neurosci, 30 , 279-290.
Shorter, E., (1997). A history of psychiatry: From the era of the asylum to the age of Prozac. New York: John Wiley & Sons, Inc.
Thiebaut de Schotten, M., Dell'Acqua, F., Ratiu, P. Leslie, A., Howells, H., Cabanis, E., Iba-Zizen, M.T., Plaisant, O., Simmons, A, Dronkers, N.F., Corkin, S., & Catani, M. (2015). From Phineas Gage and Monsieur Leborgne to H.M.: Revisiting disconnection syndromes. Cerebral Cortex, 25 , 4812-4827.
David, A.S., Fleminger, S., Kopelman, M.D., Lovestone, S., & Mellers, J. (2009). Lishman's organic psychiatry: A textbook of neuropsychiatry. Hoboken, NJ: Wiley-Blackwell.
Kalia, M., & Costa e Silva, J. (2015). Biomarkers of psychiatric diseases: Current status and future prospects. Metabolism, 64, S11-S15.
Dronkers, N.F., Plaisant, O., Iba-Zizen, M.T., & Cabanis, E.A. (2007). Paul Broca's historic cases: High resolution MR Imaging of the brains of Leborgne and Lelong. Brain , 130, 1432–1441.
Scoville, W.B., & Milner, B. (1957). Loss of recent memory after bilateral hippocampal lesions. J. Neurol. Neurosurg. Psychiat., 20, 11-21.
Melissa Shepard, MD , is an assistant professor of psychiatry at the Johns Hopkins School of Medicine.
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Module 13: Disorders of Childhood and Adolescence
Case studies: disorders of childhood and adolescence, learning objectives.
- Identify disorders of childhood and adolescence in case studies
Case Study: Jake
Jake was born at full term and was described as a quiet baby. In the first three months of his life, his mother became worried as he was unresponsive to cuddles and hugs. He also never cried. He has no friends and, on occasions, he has been victimized by bullying at school and in the community. His father is 44 years old and describes having had a difficult childhood; he is characterized by the family as indifferent to the children’s problems and verbally violent towards his wife and son, but less so to his daughters. The mother is 41 years old, and describes herself as having a close relationship with her children and mentioned that she usually covers up for Jake’s difficulties and makes excuses for his violent outbursts. 
During his stay (for two and a half months) in the inpatient unit, Jake underwent psychiatric and pediatric assessments plus occupational therapy. He took part in the unit’s psycho-educational activities and was started on risperidone, two mg daily. Risperidone was preferred over an anti-ADHD agent because his behavioral problems prevailed and thus were the main target of treatment. In addition, his behavioral problems had undoubtedly influenced his functionality and mainly his relations with parents, siblings, peers, teachers, and others. Risperidone was also preferred over other atypical antipsychotics for its safe profile and fewer side effects. Family meetings were held regularly, and parental and family support along with psycho-education were the main goals. Jake was aided in recognizing his own emotions and conveying them to others as well as in learning how to recognize the emotions of others and to become aware of the consequences of his actions. Improvement was made in rule setting and boundary adherence. Since his discharge, he received regular psychiatric follow-up and continues with the medication and the occupational therapy. Supportive and advisory work is done with the parents. Marked improvement has been noticed regarding his social behavior and behavior during activity as described by all concerned. Occasional anger outbursts of smaller intensity and frequency have been reported, but seem more manageable by the child with the support of his mother and teachers.
In the case presented here, the history of abuse by the parents, the disrupted family relations, the bullying by his peers, the educational difficulties, and the poor SES could be identified as additional risk factors relating to a bad prognosis. Good prognostic factors would include the ending of the abuse after intervention, the child’s encouragement and support from parents and teachers, and the improvement of parental relations as a result of parent training and family support by mental health professionals. Taken together, it appears that also in the case of psychiatric patients presenting with complex genetic aberrations and additional psychosocial problems, traditional psychiatric and psychological approaches can lead to a decrease of symptoms and improved functioning.
Case Study: Kelli
Kelli may benefit from a course of comprehensive behavioral intervention for her tics in addition to psychotherapy to treat any comorbid depression she experiences from isolation and bullying at school. Psychoeducation and approaches to reduce stigma will also likely be very helpful for both her and her family, as well as bringing awareness to her school and those involved in her education.
- Kolaitis, G., Bouwkamp, C.G., Papakonstantinou, A. et al. A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability, and 47,XXY syndrome in combination with a 7q11.23 duplication, 11p15.5 deletion, and 20q13.33 deletion. Child Adolesc Psychiatry Ment Health 10, 33 (2016). https://doi.org/10.1186/s13034-016-0121-8 ↵
- Case Study: Childhood and Adolescence. Authored by : Chrissy Hicks for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
- A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability.... Authored by : Gerasimos Kolaitis, Christian G. Bouwkamp, Alexia Papakonstantinou, Ioanna Otheiti, Maria Belivanaki, Styliani Haritaki, Terpsihori Korpa, Zinovia Albani, Elena Terzioglou, Polyxeni Apostola, Aggeliki Skamnaki, Athena Xaidara, Konstantina Kosma, Sophia Kitsiou-Tzeli, Maria Tzetis . Provided by : Child and Adolescent Psychiatry and Mental Health. Located at : https://capmh.biomedcentral.com/articles/10.1186/s13034-016-0121-8 . License : CC BY: Attribution
- Angry boy. Located at : https://www.pxfuel.com/en/free-photo-jojfk . License : Public Domain: No Known Copyright
- Frustrated girl. Located at : https://www.pickpik.com/book-bored-college-education-female-girl-1717 . License : Public Domain: No Known Copyright
Psychological Disorders: Case Studies Case Study 1: For the past...
Psychological Disorders: Case Studies Case Study 1:
For the past few weeks Mary has felt extremely tired. She's called in sick several times and has a hard time concentrating when she is at work. Her coworkers have noticed that she is often irritable and withdrawn, which is quite different from her typically upbeat and friendly nature. She used to enjoy meeting her friends for coffee and playing raquetball at their local club, but lately does not feel like hanging out with anyone, believing she wouldn't be good company anyway.
Mary has been having trouble sleeping and when she does fall asleep she wakes up several times during the night. She cries often, which is not like her. She doesn't seem to want to talk to her husband about her feelings and doesn't appear to want to get close to him.
Mary is unhappy with her life. She gets frustrated with herself because she feels like she has every reason to be happy, yet can't seem to shake the sense of doom and gloom that has been clouding each day as of late.
1. Diagnosis of Mary ( only list one diagnosis so choose the best one ): Be sure to provide a thorough explanation for your answer listing specific information from the case study in your determination and support your diagnosis using information from the learning materials & your textbook.
2. What treatment do you believe to be best for Mary? (list more than 1 treatment option )
3. Why do you believe this treatment would be beneficial? (support your ideas with information from the textbook or learning materials)
Textbook reference: Psychology (Spielman, R. M.). OpenStax, Rice University, Houston, TX
Answer & Explanation
1) Diagnosis of Mary: Major Depressive Disorder (MDD)
Explanation: Mary's symptoms align with the criteria for Major Depressive Disorder. She exhibits persistent feelings of fatigue, difficulty concentrating, irritability, withdrawal from social activities, changes in sleep patterns (insomnia), frequent crying, and an overall sense of unhappiness and hopelessness. These symptoms have been present for a few weeks, indicating a significant impact on her daily functioning. The fact that Mary acknowledges having every reason to be happy but cannot shake the feeling of doom and gloom is consistent with the negative cognitive patterns often observed in individuals with depression.
2) Treatment Options for Mary:
- a. Psychotherapy (Cognitive-Behavioral Therapy - CBT): CBT is a widely used and effective therapeutic approach for treating Major Depressive Disorder. It focuses on identifying and challenging negative thought patterns and behaviors, helping individuals develop healthier coping mechanisms. In Mary's case, addressing her distorted thoughts about herself, her life, and her relationships can contribute to a more positive outlook.
- b. Medication (Antidepressant medication): Selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) are commonly prescribed medications for depression. These medications can help regulate neurotransmitter levels in the brain, alleviating depressive symptoms. Considering the severity of Mary's symptoms, medication may be a valuable adjunct to psychotherapy
3) Rationale for Treatment Options:
a. Cognitive-Behavioral Therapy (CBT): CBT is based on the premise that changing maladaptive thought patterns can lead to changes in emotions and behaviors. Given Mary's negative thinking, withdrawal from enjoyable activities, and difficulty expressing her feelings, CBT can help her identify and challenge these negative thoughts, develop better coping strategies, and rebuild a more positive and adaptive mindset.
b. Antidepressant Medication: Medication can provide relatively quicker relief from severe depressive symptoms, making it easier for individuals to engage in psychotherapy. The combination of medication and therapy has been shown to be particularly effective in treating moderate to severe depression. Medication can help regulate neurotransmitter imbalances that contribute to depressive symptoms, providing a foundation for Mary to actively participate in therapy and make necessary lifestyle changes.
It's important to note that the choice of treatment should be made in consultation with a mental health professional, and the effectiveness of the treatment may vary from person to person.
Psychology : Spielman, Rose M., author : Free Download, Borrow, and Streaming : Internet Archive . (2014). Internet Archive. https://archive.org/details/Psychology_201906
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