Anorexia nervosa (differential diagnoses)

For other uses, see Anorexia nervosa (disambiguation).

Anorexia Nervosa
Classification and external resources
ICD-10	F50.0-F50.1
ICD-9	307.1
OMIM	606788
DiseasesDB	749
eMedicine	emerg/34 med/144

The differential diagnoses of anorexia nervosa (AN) include various medical and psychological conditions which may be misdiagnosed as (AN), in some cases these conditions ,ay be comorbid with anorexia nervosa (AN). The misdiagnosis of AN is not uncommon. In one instance a case of achalasia was misdiagnosed as AN and the patient spent two months confined to a psychiatric hospital.^[1]

Medical

Some of the differential or comorbid medical diagnoses may include:

• achalasia; There have been cases where achalasia, a disorder of the esophagus which affects peristalsis, has been misdiagnosed as AN. It has been reported in cases where there is sub-clinical manifestation of anorexia nervosa and also in cases where the full diagnostic criteria AN has been met.^[2]
• acute pandysautonomia is one form of an autonomic neuropathy, which are a collection of various syndromes and diseases which affect the autonomic neurons of the autonomic nervous system (ANS). Autonomic neuropathies may be the result of an inherited condition or they may be acquired due to various premorbid conditions such as diabetes and alcoholism, bacterial infection such as Lyme disease or a viral illness. Some of the symptoms of ANS which may be associated with an ED include nausea, dysphagia, constipation, pain in the salivary glands early saiety. It also affects peristalsis in the stomach. Acute pandysautonomia may cause emotional instability and has been misdiagnosed as various psychiatric disorders including hysterical neurosis and anorexia nervosa.^[3]
• Lupus: various neuropsychiatric symptoms are associated with systemic lupus erythematosus (SLE), including depression.Anorexia and weight loss also may occur with SLE and while rare it may be misdiagnosed as AN.^[4][5]
• Lyme Disease is known as the "great imitator", as it may present as a variety of psychiatric or neurologic disorders including anorexia nervosa. "A 12 year old boy with confirmed Lyme arthritis treated with oral antibiotics subsequently became depressed and anorectic. After being admitted to a psychiatric hospital with the diagnosis of anorexia nervosa, he was noted to have positive serologic tests for Borrelia burgdorferi. Treatment with a 14 day course of intravenous antibiotics led to a resolution of his depression and anorexia; this improvement was sustained on 3 year follow-up."^[6][7] Serologic testing can be helpful but should not be the sole basis for diagnosis. The Centers for Disease Control (CDC) issued a cautionary statement (MMWR 54;125) regarding the use of several commercial tests. Clinical diagnostic criteria has been issued by the CDC (CDC, MMWR 1997; 46: 531-535).
• Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is a rare genetic disorder characterized by gastrointestinal dysmotility, severe cachexia progressive external ophthalmoplegia, post-prandial emesis (vomiting after eating), peripheral neuropathy, and diffuse leukoencephalopathy. Onset is prior to age 20 in 60% of cases. ""Miss A" was a 21-year-old Indian woman diagnosed as having treatment-resistant anorexia nervosa." It was subsequently proven to be MNGIE^[8][9][10]
• superior mesenteric artery syndrome: (SMA) syndrome; "is a gastrointestinal disorder characterized by the compression of the third or transverse portion of the duodenum against the aorta by the superior mesenteric artery resulting in chronic partial, incomplete, acute or intermittent duodenal obstruction". It may occur as a complication of AN or as a differential diagnosis. There have been reported cases of a tentative diagnosis of AN, where upon treatment for SMA syndrome the patient is asymptomatic.^[11][12]
• Addison's Disease; is a disorder of the adrenal cortex which results in decreased hormonal production. Addison's disease, even in subclinical form may mimic many of the symptoms of anorexia nervosa.^[13]
• Brain tumors: There are multiple cases were the neuropsychiatric symptoms of a brain tumor were attributed to AN resulting in misdiagnosis. The tumors in these cases were noted in various regions of the brain including the medulla oblongata, hypothalamus, pituitary gland, pineal gland and the obex.^{[14][15][16][17]}
  • Simmond's disease (organic hypopituitarism) – "A 20-year-old Japanese man with a hypothalamic tumor which caused hypopituitarism and diabetes insipidus was mistakenly diagnosed as anorexia nervosa because of anorexia, weight loss, denial of being ill, changes in personality, and abnormal behavior resembling the clinical characteristics of anorexia nervosa"^[18]
  • Brain calcification either dystrophic calcification or metastatic calcification can present with neuropsychiatric symptoms including those associated with AN and comorbid disorders such as obsessive compulsive disorder.^[19][20]
  • cysts that occur in the central nervous system such as dermoid cysts and arachnoid cysts can cause neuropsychiatric symptoms including psychosis.^[21][22]
• Celiac Disease is an inflammatory disorder triggered by peptides from wheat and similar grains which cause an immune reaction in the small intestine."information on the role of the gastrointestinal system in causing or mimicking eating disorders is scarce."(Leffler DA et al.)^[23]
• Gall bladder disease which may be caused by inflammation, infection, gallstones, obstruction of the gallbladder or torsion of the gall bladder. Many of the symptoms of gall bladder disease may mimic anorexia nervosa (AN). Laura Daly, a woman from Missouri, suffered from an inherited disorder in which the gall bladder was not properly attached; the resultant complications led to multiple erroneous diagnoses of AN. Upon performance of a CCK test, standard imaging techniques are done with the patient lying prone, in this instance it was done with the patient in an upright position. The gall bladder was shown to be in an abnormal position having flipped over the liver. The gallbladder was removed and the patient has since recovered. The treatment was performed by William P. Smedley, M.D., F.A.C.S. in Pennsylvania.
• colonic tuberculosis misdiagnosed as anorexia nervosa in a physician at the hospital where she worked. "This patient, who had severe wasting, was misdiagnosed as having anorexia nervosa despite the presence of other symptoms suggestive of an organic disease, namely, fever and diarrhea"(Madani, A 2002).^[24]
• Crohn's Disease: "We report three cases of young 18 to 25 year-old girls, initially treated for anorexia nervosa in a psychiatric department. Diagnosis of Crohn's disease was made within 5 to 13 years."(Blanchet C, Luton JP. 2002)"This disease should be diagnostically excluded before accepting anorexia nervosa as final diagnosis". (Wellmann W et al.)^{[25][26][27][28]}
• hypothyroidism, hyperthyroidism, hypoparathyroidism and hyperparathyroidism may mimic some of the symptoms of, can occur concurrently with, be masked by or exacerbate an eating disorder and/or various comorbid disorders such as anxiety and depression.^{[29][30][31][32][33][34][35][36]}
• Insulinomas, are (pancreatic tumors) that cause an overproduction of insulin, causing hypoglycemia. Various neurological deficits have been ascribed to this condition including misdiagnosis as an eating disorder.^{[37][38][39][40][41]}
• Multiple sclerosis (Encephalomyelitis disseminata) is a progressive autoimmune disorder in which the protective covering (myelin sheath) of nerve cells is damaged as a result of inflammation and resultant attack by the bodies own immune system. In its initial presentation MS has been misdiagnosed as an eating disorder.^[42]

Psychological

There are various other psychological issues that may factor into anorexia nervosa, some fulfill the criteria for a separate Axis I diagnosis or a personality disorder which is coded Axis II and thus are considered comorbid to the diagnosed eating disorder. Axis II disorders are subtyped into 3 "clusters", A, B and C.The causality between personality disorders and eating disorders has yet to be fully established.^[43] Some people have a previous disorder which may increase their vulnerability to developing an eating disorder.^[44][45][46] Some develop them afterwards.^[47] The severity and type of eating disorder symptoms have been shown to affect comorbidity.^[48] These comorbid disorders themselves have multiple differential diagnoses, such as depression which may be caused by such disparate causes such as Lyme disease or hypothyroidism.

• Body dysmorphic disorder (BDD) is listed as a somatoform disorder that affects up to 2% of the population. BDD is characterized by excessive rumination over an actual or perceived physical flaw. BDD has been diagnosed equally among men and women. While BDD has been misdiagnosed as anorexia nervosa, it also occurs comorbidly in 25% to 39% of AN cases.^[49]

BDD is a chronic and debilitating condition which may lead to social isolation, major depression, suicidal ideation and attempts. Neuroimaging studies to measure response to facial recognition have shown activity predominately in the left hemisphere in the left lateral prefrontal cortex, lateral temporal lobe and left parietal lobe showing hemispheric imbalance in information processing. There is a reported case of the development of BDD in a 21 year old male following an inflammatory brain process. Neuroimaging showed the presence of new atrophy in the frontotemporal region.^{[50][51][52][53][54]}

• Emetophobia is an anxiety disorder characterized by an intense fear of vomiting. A person so afflicted may develop rigorous standards of food hygiene, such as not touching food with their hands. They may become socially withdrawn to avoid situations which in their perception may make them vomit. Many who suffer from emetophobia are diagnosed with anorexia or self-starvation. In severe cases of emetophobia they may drastically reduce their food intake.^[55][56]
• phagophobia is an anxiety disorder characterized by a fear of eating, it is usually initiated by an adverse experience while eating such as choking or vomiting. Individuals with this disorder may present with complaints of pain while swallowing. There have been cases of it being misdiagnosed as AN.^[57][58] A similar phobic anxiety disorder, swallowing phobia may also lead to a misdiagnosis of anorexia nervosa; such individuals do not want to lose weight but typically want to put weight back on that they have lost due to their phobia.^[59]

Comorbid Disorders
Axis I	Axis II
depression[60]	obsessive compulsive personality disorder[61]
substance abuse, alcoholism[62]	borderline personality disorder[63]
anxiety disorders[64]	narcissistic personality disorder[65]
obsessive compulsive disorder[66][67]	histrionic personality disorder[68]
Attention-Deficit-Hyperactivity-Disorder[69][70][71][72]	avoidant personality disorder[73]

The distinction between the diagnoses of anorexia nervosa, bulimia nervosa and eating disorder not otherwise specified (EDNOS) is often difficult to make as there is considerable overlap between patients diagnosed with these conditions. Seemingly minor changes in a patient's overall behavior or attitude can change a diagnosis from "anorexia: binge-eating type" to bulimia nervosa. It is not unusual for a person with an eating disorder to "move through" various diagnoses as his or her behavior and beliefs change over time.^[74]

References

1. ^ Marshall JB, Russell JL. Achalasia mistakenly diagnosed as eating disorder and prompting prolonged psychiatric hospitalization.South Med J. 1993 Dec;86(12):1405-7.doi:10.1097/00007611-199312000-00019 PMID 8272922
2. ^ Riterrrich A,et al.Achalasia mimicking pre-pubertal anorexia. Int J Eat Disord 2003 Apr.33;(3):356-9 [PMID 12655633]
3. ^ Okada F.Psychiatric aspects of acute pandysautonomia. Eur Arch Psychiatry Clin Neurosci. 1990;240(2):134-5.PMID 2149650
4. ^ Neuropsychiatric systemic lupus erythematosus presenting as bipolar I disorder with catatonic features. Alao AO, Chlebowski S, Chung C. Psychosomatics. 2009 Sep-Oct;50(5):543-7. doi:10.1176/appi.psy.50.5.543 PMID 19855042
5. ^ Preventing Misdiagnosis of Women: A Guide to Physical Disorders That Have Psychiatric Symptoms (Women's Mental Health and Development)by Dr. Elizabeth Adele Klonoff and Dr. Hope Landrine. Page 87 Publisher: Sage Publications, Inc; 1 edition (November 13, 1997) Language: English ISBN 0-7619-0047-0 ISBN 978-0-7619-0047-4
6. ^ Fallon BA, Nields JA. Lyme disease: a neuropsychiatric illness. Am J Psychiatry. 1994 Nov;151(11):1571-83. PMID 7943444
7. ^ Pachner AR. Borrelia burgdorferi in the Nervous System: the New "Great Imitator." In Lyme Disease and Related Disorders. Annals New York Academy of Sciences 539: 56-64, 1988. doi:10.1111/j.1749-6632.1988.tb31838.x PMID 3190104
8. ^ Feddersen B. Mitochondrial neurogastrointestinal encephalomyopathy mimicking anorexia nervosa. Am J Psychiatry. 2009 Apr;166(4):494-5.PMID 19339372
9. ^ Mitochondrial Neurogastrointestinal Encephalomyopathy Mimicking Anorexia Nervosa Article
10. ^ Mitochondrial Neurogastrointestinal Encephalopathy Disease
11. ^ Gerasimidis T. Superior mesenteric artery syndrome, Wilkie Syndrome. Dig Surg 2009 26;(3):213-14 PMID 19468230
12. ^ Kornmehl P.Superior mesenteric artery syndrome presenting as anorexia-like illness. J Adolscen Health Care 1988 Jul;9(4):30-3 PMID 3417512
13. ^ Adams R et al.Prompt differentiation of Addison's disease from anorexia nervosa during weight loss and vomiting. South Med J. 1998 Feb;91(2):208-11. PMID 9496878
14. ^ L. et al.Brain tumor presenting as anorexia nervosa in a 19-year-old man. Brain tumors:J Formos Med Assoc. 2003 Oct;102(10):737-40.PMID 14691602
15. ^ Sokol MS.et al.nervosa and brain tumor in a 14-year-old girl.CNS Spectr. 2006 Sep;11(9):669-73; quiz 719.PMID 16946691
16. ^ Grossmann D. et al.[Cavernoma of the medulla oblongata mimicking "Anorexia nervosa" - a case report] [Article in German]Klin Padiatr. 2002 Jan-Feb;214(1):41-4.PMID 11823953
17. ^ Pavesi G. et al.Hemangioblastoma of the obex mimicking anorexia nervosa. Neurology. 11 July 2006;67(1):178-9. PMID 16832109
18. ^ Hotta M.et al. A Young Man With a Hypothalimic Tumor Mimicking Anorexia Nervosa Accession number;99A0720003 Journal of Tokyo Women's Medical University Journal Code:G0684A ISSN:0040-9022VOL.69;NO.6;PAGE.289-295(1999)
19. ^ Conrad R. et al. Nature against nurture: calcification in the right thalamus in a young man with anorexia nervosa and obsessive-compulsive personality disorder.CNS Spectr. 2008 Oct;13(10):906-10.PMID 18955946
20. ^ López-Villegas D.Neuropsychological alterations in patients with computed tomography-detected basal ganglia calcification. Arch Neurol. 1996 Mar;53(3):251-6.PMID 8651878
21. ^ Wolańczyk T. et al.Catatonic syndrome preceded by symptoms of anorexia nervosa in a 14-year-old boy with arachnoid cyst.Eur Child Adolesc Psychiatry. 1997 Sep;6(3):166-9.PMID 9383651
22. ^ da Silva et al. (2007). "Arachnoid cyst in a patient with psychosis: Case report". Ann Gen Psychiatry 6 (16): 16. doi:10.1186/1744-859X-6-16. 
23. ^ Leffler DA, Dennis M, Edwards George JB, Kelly CP.The interaction between eating disorders and celiac disease: an exploration of 10 cases. Eur J Gastroenterol Hepatol. 2007 Mar;19(3):251-5. PMID 17301653
24. ^ Tariq A Madani, MD. Colonic tuberculosis clinically misdiagnosed as anorexia nervosa, and radiologically and histopathologically as Crohn's disease Can J Infect Dis. 2002 Mar–Apr; 13(2): 136–140. PMCID: PMC2094857
25. ^ Blanchet C, Luton JP.Anorexia nervosa and Crohn disease: diagnostic intricacies and difficulties. 3 cases 3 cases Presse Med. 23 February 2002;31(7):312-5. PMID 11899685
26. ^ Holaday M, Smith KE, Robertson S, Dallas J. Adolescence. An atypical eating disorder with Crohn's disease in a fifteen-year-old male: a case study. 1994 Winter;29(116):865-73. PMID 7892797
27. ^ Wellmann W, Pries K, Freyberger H. [Combination of Crohn's disease and anorexia nervosa signs and symptoms. Dtsch Med Wochenschr. 6 November 1981;106(45):1499-502. PMID 7307984
28. ^ Rickards H, Prendergast M, Booth IW. Psychiatric presentation of Crohn's disease. Diagnostic delay and increased morbidity. Br J Psychiatry. 1994 Feb;164(2):256-61. PMID 8173832
29. ^ Mannucci E et al..Eating behavior and thyroid disease in female obese patients. Eat Behav. 2003 Aug;4(2):173-9.doi:10.1016/S1471-0153(03)00012-6 PMID 15000980
30. ^ Byerley B, Black DW, Grosser BI. Anorexia nervosa with hyperthyroidism: case report. J Clin Psychiatry. 1983 Aug;44(8):308-9. PMID 6874653
31. ^ Krahn D. Thyrotoxicosis and bulimia nervosa. Psychosomatics. 1990 Spring;31(2):222-4. PMID 2330406
32. ^ Tiller J et al.The prevalence of eating disorders in thyroid disease: a pilot study. J Psychosom Res. 1994 Aug;38(6):609-16. doi:10.1016/0022-3999(94)90058-2 PMID 7990069
33. ^ Fonseca V, Wakeling A, Havard CW.Hyperthyroidism and eating disorders. BMJ. 11 August 1990;301(6747):322-3. doi:10.1136/bmj.301.6747.322 PMID 2393739
34. ^ Birmingham CL, Gritzner S, Gutierrez E. Hyperthyroidism in anorexia nervosa: case report and review of the literature. Int J Eat Disord. 2006 Nov;39(7):619-20. doi:10.1002/eat.20308 PMID 16958126
35. ^ D Mattingly and S Bhanji Hypoglycaemia and anorexia nervosa. J R Soc Med. 1995 April; 88(4): 191–195. PMCID: PMC1295161
36. ^ Ozawa Y, Koyano H, Akama T. Complete recovery from intractable bulimia nervosa by the surgical cure of primary hyperparathyroidism. J Eat Disord. 1999 Jul;26(1):107-10. doi:10.1002/(SICI)1098-108X(199907)26:1<107::AID-EAT15>3.0.CO;2-U PMID 10349592
37. ^ Grant CS.Insulinoma. Best Pract Res Clin Gastroenterol. 2005 Oct;19(5):783-98. PMID 16253900
38. ^ Shanmugam V, Zimnowodzki S, Curtin J, Gorelick PB.Hypoglycemic hemiplegia: insulinoma masquerading as stroke. J Stroke Cerebrovasc Dis. 1997 Jul-Aug;6(5):368-9. PMID 17895035
39. ^ Morgan JR.A case of Down's syndrome, insulinoma and anorexia. J Ment Defic Res. 1989 Apr;33 ( Pt 2):185-7. PMID 2542562
40. ^ Olsen DB, Abraham JH.Neuropsychiatric disorders in insulinoma Ugeskr Laeger. 8 March 1999;161(10):1420-1. PMID 10085751
41. ^ Vig S, Lewis M, Foster KJ, Stacey-Clear A.Lessons to be learned: a case study approach insulinoma presenting as a change in personality. J R Soc Promot Health. 2001 Mar;121(1):56-61. PMID 11329699
42. ^ Dick B. Encephalomyelitis disseminata: a rare, but challenging differential diagnosis of anorectic disorder. World J Biol Psychiatry. 2002 Oct;3(4):225-8.PMID 12516315
43. ^ Rosenvinge et al. The comorbidity of eating disorders and personality disorders: a metanalytic review of studies between 1983 and 1998 Eating and Weight Disorders 2000 June;5(2):52-61 PMID 10941603
44. ^ Kaye WH Comorbidity of anxiety disorders with anorexia and bulimia nervosa. American journal of Psychiatry 2004 Dec;161(12)2215-21 doi:10.1176/appi.ajp.161.12.2215 PMID 15569892
45. ^ Thornton C, Russell J.Obsessive compulsive comorbidity in the dieting disorders Int J Eat Disord. 1997 Jan;21(1):83-7. doi:10.1002/(SICI)1098-108X(199701)21:1<83::AID-EAT10>3.0.CO;2-P PMID 8986521
46. ^ Vitousek K, Manke F. Personality variables and disorders in anorexia nervosa and bulimia nervosa. J Abnorm Psychol. 1994 Feb;103(1):137-47. doi:10.1037/0021-843X.103.1.137 PMID 8040475
47. ^ Braun Dl Psychiatric comorbidity in patients with eating disorders. Psychological Medicine 1994;24:854-67 doi:10.1017/S0033291700028956 PMID 7892354
48. ^ Spindler A, Milos G. Eat Behav. 2007 Aug;8(3):364-73. Links between eating disorder symptom severity and psychiatric comorbidity. doi:10.1016/j.eatbeh.2006.11.012 PMID 17606234
49. ^ Grant JE, Kim SW, Eckert ED. Body dysmorphic disorder in patients with anorexia nervosa: prevalence, clinical features, and delusionality of body image. Int J Eat Disord. 2002 Nov;32(3):291-300.doi:10.1002/eat.10091 PMID 12210643
50. ^ Gabbay V. New onset of body dysmorphic disorder following frontotemporal lesion. Neurology. 8 July 2003;61(1):123-5.PMID 12847173
51. ^ Phillips KA,et al.A comparison of delusional and nondelusional body dysmorphic disorder in 100 cases. Psychopharmacol Bull. 1994;30(2):179-86.PMID 7831453
52. ^ Feusner JD, Townsend J, Bystritsky A, Bookheimer S.Visual information processing of faces in body dysmorphic disorder. Arch Gen Psychiatry. 2007 Dec;64(12):1417-25.doi:10.1001/archpsyc.64.12.1417 PMID 18056550
53. ^ Feusner JD, Yaryura-Tobias J, Saxena S.Body Image. The pathophysiology of body dysmorphic disorder. 2008 Mar;5(1):3-12. Epub 7 March 2008.doi:10.1016/j.bodyim.2007.11.002 PMID 18314401
54. ^ Feusner JD, Townsend J, Bystritsky A, Bookheimer S. Arch Gen Psychiatry. 2007 Dec;64(12):1417-25. Visual information processing of faces in body dysmorphic disorder. doi:10.1001/archpsyc.64.12.1417 PMID 18056550
55. ^ Lipsitz JD, Fyer AJ, Paterniti A, Klein DF. Emetophobia: preliminary results of an internet survey. Depress Anxiety. 2001;14(2):149-52. doi:10.1002/da.1058 PMID 11668669
56. ^ Boschen MJ. Reconceptualizing emetophobia: a cognitive-behavioral formulation and research agenda. Anxiety Disord. 2007;21(3):407-19. Epub 4 August 2006. doi:10.1016/j.janxdis.2006.06.007 PMID 16890398
57. ^ Shapiro J, Franko DL, Gagne A. Phagophobia: a form of psychogenic dysphagia. A new entity. Ann Otol Rhinol Laryngol. 1997 Apr;106(4):286-90.PMID 9109717
58. ^ Okada A. et al. A study of psycho-pathology and treatment of children with phagophobia.Acta Med Okayama. 2007 Oct;61(5):261-9.PMID 17971843
59. ^ de Lucas-Taracena, MT.; Montañés-Rada, F. (2006). "[Swallowing phobia: symptoms, diagnosis and treatment"]. Actas Esp Psiquiatr 34 (5): 309–16. PMID 16991019. http://www.arsxxi.com/Revistas/fframesart.php?MTg%3D&ODUyOQ%3D%3D&MA%3D%3D&RU4%3D&&MTg%3D&Nzg5. 
60. ^ RC Casper Depression and Anxiety 1998;Suppl 1;96-104 doi:10.1002/(SICI)1520-6394(1998)8:1+<96::AID-DA15>3.0.CO;2-4 PMID 9809221
61. ^ Serpell L, Livingstone A, Neiderman M, Lask B.Anorexia nervosa: obsessive-compulsive disorder, obsessive-compulsive personality disorder, or neither? Clin Psychol Rev. 2002 Jun;22(5):647-69. PMID: 12113200
62. ^ Bulik Et. Al.Alcohol use disorder comorbidity in eating disorders: a multicenter study. Journal of Clinical Psychiatry 2004 July;65(7):1000-6 doi:10.4088/JCP.v65n0718 PMID 15291691
63. ^ Larsson JO,Hellzen MPatterns of personality disorders in women with chronic eating disorders; Eating and Weight Disorders 2004 Sep;9(3):200-5 PMID 15656014
64. ^ JN Swinburne Touz Sm The co-morbidity of eating disorders and anxiety: a review Eur Eat Disord Rev 2007 Jul;15(4):253-74 doi:10.1002/erv.784 PMID 17676696
65. ^ Ronningstam E.Pathological narcissism and narcissistic personality disorder in Axis I disorders. Harv Rev Psychiatry. 1996 Mar-Apr;3(6):326-40. doi:10.3109/10673229609017201 PMID 9384963
66. ^ Anderlich MB American Journal of Psychiatry 2003 Feb;160(2)242-7 doi:10.1176/appi.ajp.160.2.242 PMID 12562569
67. ^ Pinto A, Mancebo MC, Eisen JL, Pagano ME, Rasmussen SA. The Brown Longitudinal Obsessive Compulsive Study: clinical features and symptoms of the sample at intake. Clin Psychiatry. 2006 May;67(5):703-11.doi:10.4088/JCP.v67n0503 PMID 16841619
68. ^ Lucka I, Cebella A. Characteristics of the forming personality in children suffering from anorexia nervosa Psychiatr Pol. 2004 Nov-Dec;38(6):1011-8.PMID 15779665
69. ^ Bulimia nervosa and attention deficit hyperactivity disorder: a possible role for stimulant medication. Dukarm CP. J Women's Health (Larchmt). 2005 May;14(4):345-50. doi:10.1089/jwh.2005.14.345 PMID 15916509
70. ^ Mikami AY et, el.Bulimia nervosa symptoms in the Multimodal Treatment Study of Children with ADHD. Int J Eat Disord. 17 April 2009 doi:10.1002/eat.20692 PMID 19378318
71. ^ Biederman J. et al.Are girls with ADHD at risk for eating disorders? Results from a controlled, five-year prospective study. J Dev Behav Pediatr. 2007 Aug;28(4):302-7. doi:10.1097/DBP.0b013e3180327917 PMID 17700082
72. ^ Cortese S. et al.Attention-deficit/hyperactivity disorder (ADHD) and binge eating Nutr Rev. 2007 Sep;65(9):404-11. Nutr Rev. 2008 Jun;66(6):357. doi:10.1111/j.1753-4887.2007.tb00318.x PMID 17958207
73. ^ Bruce KR et, al.Bulimia nervosa with co-morbid avoidant personality disorder: behavioural characteristics and serotonergic function. Psychol Med. 2004 Jan;34(1):113-24.doi:10.1017/S003329170300864X PMID 14971632
74. ^ Zucker, N. L; M. Losh, C. M Bulik, K. S LaBar, J. Piven, K. A Pelphrey (2007). "Anorexia nervosa and autism spectrum disorders: Guided investigation of social cognitive endophenotypes". Psychological Bulletin 133 (6): 976–1006. doi:10.1037/0033-2909.133.6.976. PMID 17967091. http://www.duke.edu/web/mind/level2/faculty/labar/pdfs/Zucker_et_al_2007.pdf.