Investigation of compulsive exercise behaviours and comorbidity of attention deficit and hyperactivity disorder in 11-18 year-old adolescents diagnosed with anorexia nervosa and exogenous obesity.

Introduction: It is known that Anorexia Nervosa (AN) and Attention Deficit Hyperactivity Disorder (ADHD) which develop in the substructure of impulsivity, have become a serious public health issue by affecting young population. Although obesity whose prevalence increasing in young population is regarded as a candidate problem to be involved in the psychiatric disorder classification by psychiatric professionals, it has not come in on structured mental health diagnosis and treatment guidelines yet, unfortunately. On the flip side, concomitance of obesity and other eating disorders together cause us to think that obesity is neither an outcome nor a reason of eating disorders, conversely a different clinical manifestation of the same psychopathology, which may be a spectrum disorder also including impulsivity. It was observed that adolescents diagnosed with AN, ADHD or Obesity, take exercise excessively and show their exercise manners like almost at the level of dependence, in some periods of their life. When the literature is reviewed, it is seen that there is no study both all around the world and Turkey concerning the assumption of these disorders to have the common etiopathogenesis developed in the basis of impulsivity and the inference of exercise addiction to be a distinctive disorder that may accompany to these disorders. Obesity and eating disorders damage both human health and the country's economy; based on this point, correction of the hypothesis of obesity and eating disorders to be diverse manifestations of the unique and same disorder, may lead to a new approach on treatment. The aim of our study is to evaluate the additional ADHD symptoms and exercise addiction in the cases with the age range of 11 to 18 diagnosed with AN and obesity. Method: Sample of our study was comprised of 30 subjects aged between 11 and 18 and followed up with the diagnosis of Anorexia Nervosa in the Department of Child and Adolescent Psychiatry, Ege University, 30 subjects between 11 and 18 and followed up with the diagnosis of Exogenous Obesity in the Department of Pediatric Endocrinology, Ege University and 30 healthy controls having similar sociodemographic features like case groups have. First, all the subjects were evaluated according to DSM-5 Diagnostic Criteria and interviewed with semi-structured interview called Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version (K-SADS-PL) by two researchers separately. After evaluation, patients' functioning and severity of the symptoms were assessed using Global Assessment Scale (GAS) when detected accompanying subthreshold psychiatric symptoms. Of the subjects, inappropriate eating attitudes and behaviors were measured with Eating Attitudes Test-40 (EAT-40), while depression symptoms with Children's Depression Inventory (CDI) for those under 15-year-age, Beck Depression Inventory (BDI) for those 15-year-age and above, anxiety symptoms with State-Trait Anxiety Inventory (STAI), difficulties in emotion regulation with Difficulties in Emotion Regulation Scale (DERS), behavioral problems having antisocial characteristics and social cognitional features with Inventory of Callous-Unemotional Traits (ICU) and exercise addiction symptoms and their severity with Exercise Dependence Scale (EDS-21). ADHD symptoms of the cases were assessed by Turgay's ADHD Scale (ADHD DSM-4) by parents and the characteristics of Autism Spectrum Disorders (ASD) were detected using Autism Spectrum Screening Questionnaire (ASSQ) filled out by parents. Patient groups completed Clinic Global Impression Scale-Severity (CGI-S) to self-report the symptom severity of disorder they had. Results: We detected that ADHD symptom severity in Obesity group was significantly higher than AN group and healthy controls. Even so, ADHD symptom intensity was higher in AN group than controls, but this severity difference was not statistically significant. It was observed that exercise dependence risk in AN subjects was significantly higher than obese teens and healthy controls. We also found that Emotion regulation abilities in AN cases were significantly worse than in obese cases and controls. Anorexia and obese cases had significantly much more characteristics associated with ASD compared to healthy controls. AN and obese participants' depression scores were higher than controls. While AN adolescents' STAI anxiety scale scores were higher than obese group's scores; obese cases had greater anxiety scores on STAI than healthy controls had. In addition to these findings, it was determined that there was a correlation in the same direction between the increase of exercise addiction level and the increase of both anxiety level and on having trouble in emotional regulation. However, it is still unclear which factor is reason and which is result. Conclusion: We detected that ADHD symptoms were seen in higher rates in all of adolescents with AN and obesity than in healthy young population. It was ascertained that both AN and obese participants had impairment in social and emotional skills, and these groups had some overlapping characteristics with ASD. It was estimated that "obesity" which is not defined as a mental disorder yet, has numerous overlapping psychopathological features with "AN" as defined an eating disorder. It was seen that, the occurrence risk of exercise addiction as being secondarily in AN is quite high and this condition is supposed to be a crucial morbidity factor. The findings of our study highlighted the importance of recognition of ADHD symptoms, social cognitional impairments and exercise addiction in AN and obesity for more effective and permanent approach about diagnosing and treatment modalities.