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Somatic comorbidities in ADHD

Somatic comorbidities in ADHD

Adults with the highest 10% of ADHD symptom expression according to ADHD-E were 10.62-fold more likely to experience distress from physical complaints and 6.80-fold more likely to experience distress from somatization than unaffected individuals.1

The following list of somatic disorders that occur comorbidly in ADHD is sorted in descending order of frequency of occurrence in ADHD sufferers. The headings indicate the percentage of occurrence of these comorbidities in ADHD sufferers (compared to non-affected persons).

The percentages in the headings indicate the frequency of comorbidity in ADHD. Example: 48% of ADHD sufferers have musculoskeletal disorders, compared to 21.6% of non-ADHD sufferers.

1. Sleep problems - children: 68.7% (vs. 47.1%)

A Chinese study of 23,791 school children found that 68.7% of children with ADHD had poor sleep quality, compared to 47.1% of children without ADHD.2

2. Musculoskeletal disorders - 48 % (vs. 21.6 %)

  • In adult ADHD sufferers: 48.4 %3
  • For non-affected persons: 21.6 %3
    = 2 times the risk

One study found that gene variants correlating with synovitis (inflammation of the synovial membrane) and tenosynovitis (tendonitis) may causally increase ADHD risk. Conversely, ADHD gene variants appear to increase the risk of carpal tunnel syndrome.4

3. Allergies - 45% (vs. 18%)

Allergies occur more frequently in ADHD than in non-affected individuals.5
In 100 children with ADHD (average age 9 years), a study found allergy in 35%. Of the comorbidly affected, 43% had hay allergy, 37.5% had various pollen allergies, 25% had combined allergic rhinitis and bronchial asthma, 8% had urticaria, and 2% had asthma. Interestingly, allergies were found only in ADHD-C, but not in ADHD-HI or ADHD-I subtype. In addition, boys with ADHD were significantly more likely to have comorbid allergy than girls. Allergies correlated with increased ADHD symptom severity. Allergies manifested at an average age of 4 years, ADHD at an average age of 6 years. Among ADHD sufferers, 16% showed positiveb skin pricktes compared with 5% of controls. A high total IgE was found in 45% of ADHD sufferers and 18% non-affected.6
A Chinese study of 23,791 school children found that 26.1% of children with ADHD had allergies, compared with 15.2% of children without ADHD.2

Allergies are usually a consequence of excessive cortisol levels. Cortisol inhibits the inflammatory cytokines triggered by CRH (first stage of the HPA axis) and instead promotes other immune defense mechanisms directed against extracellular stressors - such as bacteria or allergens.
An excessive cortisol level or an overshooting of the cortisol response can lead to an overreaction of the immune system to external substances that are actually not really dangerous - an allergy.
For more on the immunological effect of cortisol, see Adrenal cortex (3rd stage)

Disturbances in stress hormone levels, especially cortisol, in ADHD are common.
Cortisol in ADHD

4. Gastrointestinal disorders - 41.1% (vs. 21.6%)

  • In adult ADHD sufferers: 41.1 %7
  • For non-affected persons: 21.6 %3
    = 2 times the risk

5. Diseases of the upper respiratory tract

5.1. Upper respiratory diseases in children - 40% (vs. 33.4%)

  • In ADHD-affected children: 40.1 %7
  • For non-affected persons: 33.4 %7
    = 1.3 times the risk

5.2. Upper respiratory diseases in adults - 33.7% (vs. 15.2%)

  • In adult ADHD sufferers: 33.7 %7
  • For non-affected persons: 15.2 %3
    = 2 times the risk

One study found that ADHD gene variants may causally increase the risk for chronic obstructive pulmonary disease.4

6. Metabolic disorders - 36.2 % (vs. 19 %)

  • In adults with ADHD: 36.5 %8
  • For non-affected persons: 19.0 %7
    = 2 times the risk

7. Skin diseases, neurodermatitis, eczema, lichen - 32,4 % (vs. 10 to 25,5 %)

  • In ADHD-affected children: 32.4 %7
  • In unaffected individuals: 25.5%7; 10-20% in children, 2-3% in adults, with higher incidence in urban environments.9
    = about 1.5 times the risk in children9 which is supposed to explain 9% of all ADHD cases.
  • ADHD sufferers have an above-average incidence of neurodermatitis (= atopic eczema)10
  • Conversely, neurodermatitis sufferers have an increased risk of mental disorders such as ADHD.1112 13 14 15
    • A study of Indian children with atopic dermatitis found rates of16
      • Inattention: 29.5
      • Hyperactivity: 20 %
  • Epidemiological data show that the worldwide prevalence of atopic dermatitis and ADHD has increased in parallel. Several cross-sectional studies indicated a co-occurrence and a temporal co-emergence in affected individuals.9
  • Atopic immune disorders could be due to an exaggerated immune response due to lowered cortisol levels. Cortisol inhibits the inflammation initially promoted by CRH (first stage of the HPA axis) by means of inflammatory cytokines. If cortisol release (third stage of the HPA axis) is too low, inflammation is not sufficiently inhibited.17
  • Those affected by lichen showed mental disorders in 90% of cases, while non-affected persons showed mental disorders in 20% of cases. Lichen sufferers had an ADHD prevalence of 36.6%.18
  • In a mouse model of atopic dermatitis, one study found chronically increased HPA axis function and dopamine and norepinephrine alterations in locus coeruleus, PFC, and striatum, typical of ADHD. In addition, melatonin was decreased.9
    • The finding may confirm our view that chronic stress mediates its symptoms in the same way as ADHD, namely through decreased levels of dopamine and norepinephrine in the aforementioned brain areas.

For more on the immunological effect of cortisol, see Adrenal cortex (3rd stage)

Disturbances in stress hormone levels, especially cortisol, in ADHD are common.
Cortisol in ADHD

One study found increased risks in ADHD sufferers for:19

  • Atopic dermatitis: OR = 1.53
  • Urticaria (hives): OR = 1.39

It further seems interesting to us that inflammation is often accompanied by highly elevated levels of adenosine.20 At the same time, A2A and A3 receptors are overexpressed in lymphocytes in chronic autoimmune rheumatic diseases. A2A and A3 agonists inhibited NF-κB activation, release of typical proinflammatory cytokines, and levels of metalloproteinases involved in inflammatory responses in chronic autoimmune rheumatic diseases.21 Adenosine inhibits dopamine, particularly in the striatum and other brain regions relevant to ADHD. In this respect, it would be at least theoretically conceivable that inflammation could also cause ADHD symptoms through elevated levels of adenosine. More on adenosine at Adenosine In the chapter Neurological Aspects

8. Infectious diseases - 31.2 % (vs. 25.9 %)

  • In ADHD-affected children: 31.2 %7
  • For non-affected persons: 25.9 %3
    = 1.3 times the risk

9. Ear diseases - 31.1% (vs. 23.7%)

  • In ADHD-affected children: 31.1 %7
  • For non-affected persons: 23.7 %7
    = 1.7 times the risk

A Chinese study of 23,791 school children found that 6.7% of children with ADHD had had otitis media, compared with 3.8% of children without ADHD.2
Since past presence is likely to have been queried, this is less of a comorbidity and more of a risk factor

10. Obesity - D: 22.1% (vs. 10.2%); U.S.: 41.4% (vs. 21.6%)

The doubling of the frequency of obesity in ADHD sufferers is given (albeit with extremely different starting levels) in the USA from 21.6% without ADHD to 41.4% with ADHD22 as well as in Germany from 10.2% without ADHD to 22.1% with ADHD.23
An Israeli cohort study found obesity to be almost twice as common in adolescents with severe ADHD as in those not affected, at 13.5%, and about 30% more common in those with mild ADHD-HI than in those not affected.24

A Chinese study of 23,791 school children found that 32.6% of children with ADHD had overweight or obesity, compared with 29.6% of children without ADHD.2 For overweight, 15.9% were cited, and for obesity, 11.9% were cited, but not separated by ADHD status. Since the figures for obesity were not issued separately, they are not comparable.

According to Winkler, 30% to 60% of all severe obesity cases are linked to ADHD.25

Among adult psychiatric clinical patients with ADHD, the prevalence of obesity is 24.5% and of other eating disorders is 11.2%26 Other sources do not cite percentages in accessible abstracts.27

ADHD treatment of ADHD sufferers with obesity resulted in a weight loss of over 12.3%, while in the control group of non-ADHD sufferers with obesity there was a weight gain of 2.8%.28

Winkler reports that in pure obesity treatment, a weight gain of less than 5% is already considered a success,29 so that a weight loss of more than 12% seems downright sensational.

For more information, see -&gt ADHD, obesity and eating disorders In the chapter Treatment / Comorbidities.

11. Tonsillar or adenoid hypertrophy / enlarged tonsils or adenoids - 20.0% (vs. 11.1%)

A Chinese study of 23,791 school children found that 20.0% of children with ADHD had enlarged tonsils or adenoids, compared with 11.1% of children without ADHD.2
Adenotonsillar hypertrophy is the main cause of obstructive sleep apnea in childhood. Obstructive sleep apnea, in turn, is a possible cause of ADHD symptoms.

12. Asthma - 16.2% (vs. 9.7%)

In ADHD sufferers, a cohort study found asthma in 16.2%, compared with 9.7% in nonaffected individuals.30 Asthma correlated with the total number of ADHD-HI symptoms and with the total number of hyperactivity/impulsivity symptoms, but less so with inattention symptoms.
Children with asthma had a 70% increased risk of having ADHD at the same time. The risk of ODD was also increased (360%), but not the risk of CD.31 Another study found ADHD in 11.3% of those with asthma.32
There appears to be genetic overlap between ADHD (and major depression) with asthma.3330
One study found increased risks in ADHD sufferers for:19

  • Asthma: 1.53-fold risk (OR)
  • Allergic rhinitis: OR = 1.59
  • Atopic dermatitis: OR = 1.53
  • Urticaria (hives): OR = 1.39

It seems interesting to us that asthma and inflammatory diseases are often associated with highly elevated levels of adenosine.2034 At the same time, A2A and A3 receptors are overexpressed in lymphocytes in chronic autoimmune rheumatic diseases. A2A and A3 agonists inhibited NF-κB activation, release of typical proinflammatory cytokines, and levels of metalloproteinases involved in inflammatory responses in chronic autoimmune rheumatic diseases.21 Adenosine inhibits dopamine, particularly in the striatum and other brain regions relevant to ADHD. In this respect, it would be at least theoretically conceivable that asthma and inflammatory diseases could also cause ADHD symptoms through elevated levels of adenosine. More on adenosine at Adenosine In the chapter Neurological Aspects
In conclusion, successful treatment of allergic rhinitis in children significantly reduces their ADHD symptoms, but not those of children with non-allergic rhinitis.35

13. Underweight, etc. - in China: 19.9% (vs. 14.3%)

A Chinese study of 23,791 school children found:2

  • Stunting (Stunted)
    • In 9.8% of children with ADHD
    • Without 5.9 % of children without ADHD
  • Underweight
    • In 3.0% of children with ADHD
    • Without 2.9 % of children without ADHD
  • Emaciation
    • In 7.1% of children with ADHD
    • Without 5.5 % of children without ADHD

14. Celiac disease (gluten intolerance)

A larger study found an ADHD prevalence of 1.4% in children with celiac disease and an overall reduced prevalence of mental disorders.36 A smaller study found an ADHD prevalence of 16%.37
One review confirmed a correlation of celiac disease and ADHD.38

Celiac disease appears to correlate with decreased levels of dopamine, norepinephrine, and serotonin in brain CSF.394041

15. Diabetes

It seems interesting to us that diabetes is often associated with highly elevated levels of adenosine.20 Adenosine inhibits dopamine, particularly in the striatum and other brain regions relevant to ADHD. In this respect, it would be at least theoretically conceivable that diabetes could also cause ADHD symptoms through elevated adenosine levels. More on adenosine at Adenosine In the chapter Neurological Aspects

15.1. Type 1 diabetes - 12 %

Among adolescents with diabetes 1, the ADHD rate is increased. One study found ADHD in 12% of adolescents with type 1 diabetes mellitus.42

15.2. Type 2 diabetes - 3.9% (vs. 1.62%)

Type 2 diabetes was found in 3.90% (males: 4.32%; females: 3.58%) of adult ADHD sufferers compared with 1.62% (males: 1.96%; females: 1.28%) of non-sufferers, according to a large Swedish cohort study.43

One study found that gene variants correlated with diabetes 2 may causally increase ADHD risk.4

16. Premature birth suffered - 8.7% (vs. 5.5%)

A Chinese study of 23,791 school children found that 8.7% of children with ADHD had been born via preterm birth, compared to 5.5% of children without ADHD.2
This is not a comorbidity, but a risk factor

17. Hypertension - 8.5% (vs. 4.5%)

Hypertension was found in 8.51% (males: 9.57%, females: 7.39%) of adult ADHD sufferers compared with 4.48% (males: 4.98%, females: 3.98%) of nonaffected individuals, according to a large Swedish cohort study.43

18. Gastroesophageal reflux - 4.3% (vs. 0.6%)

A Chinese study of 23,791 school children found that 4.3% of children with ADHD had gastroesophageal reflux (ascending gastric juice), compared with 0.6% of children without ADHD.2

19. Visual disturbances - up to 2.4% (vs. 1.3%)

One large study found that children with ADHD-HI have significantly higher prevalences of eye disorders:44

  • Farsightedness, hypermetropia (2.4% in ADHD, 1.3% in unaffected, OR 1.82)
  • Low vision, amblyopia (1.6% in ADHD, 0.9% in unaffected, OR 1.89)
  • Manifest strabismus, heterotropia (1.1% in ADHD, 0.5% in unaffected, OR 2.01)
  • Corneal curvature, astigmatism (0.2 % in ADHD, 0.1 % in non-affected, OR 1.73)

20. Psychogenic and Functional Breathing Disorders (PFBD)

Among children affected by PBFD, one study found ADHD in 17.3%, tic disorders in 15.4%, specific phobias in 15.4%, somatic symptom disorder in 11.5%, and 51.9% showed clinical features of tic disorders.45

21. Cerebral palsy / spasticity

Cerebral palsy may be a consequence of encephalitis in which the dopaminergic cells have been destroyed. The result is a severe lack of dopamine. Treatment with L-dopa can help in such cases.
A study of 213 children with cerebral palsy found suspected ADHD in 50%, which was confirmed in 23%.46 This corresponds to a 4.6-fold ADHD risk in cerebral palsy.

22. Iron Deficiency Anemia

One study found that gene variants that correlate with iron deficiency anemia (a blood disorder) may causally increase ADHD risk.4

23. Raynaud’s syndrome

Raynaud’s syndrome is a circulatory disorder of the extremities. Fingers become pale or even blue and cold from the tips due to spasmodic constriction of blood vessels.
Raynaud’s problems are a more common comorbidity in ADHD sufferers.
Raynaud’s disease is treated with alpha-1-adrenoceptor antagonists, e.g., prazosin or tamsulosin (highly selective at prostatic alpha-1-adrenoceptors), among others.
As we understand it, the ADHD-I problems of decision-making problems and daydreaming result from too frequent shutdowns of the PFC. Dietrich calls this posteriorization of behavioral control47. These PFC shutdowns are triggered by excessive noradrenal stress responses and cortisol stress responses at alpha-1 adrenoceptors, typical of the excessive endocrine stress response of ADHD-I.
This firstly raises the question of whether Raynaud’s problems are more common in ADHD-I than in ADHD-HI.

We recall at least one ADHD-I sufferer who suffered significantly from Raynaud’s and hypertension, which was exacerbated by MPH and less evident under Elvanse.

24. Hyperthyroidism / Hyperthyroidism

Other synonyms include hyperthyroidism, hyperthyroidism, thyroid hormone toxicity.

Military personnel with hyperthyroidism were 70% more likely to have ADHD.48 68.3% of those affected had first received their ADHD diagnosis and only later received their diagnosis of hyperthyroidism.
Another study found a 2.53-fold risk (OR) for autoimmune thyroid hormone disorders in ADHD sufferers.19

25. Endometriosis

Women with endometriosis had a doubled risk (OR 1.98) of ADHD than their sisters without endometriosis.49

26. Polyarthritis

One study found that gene variants correlated with polyarthritis may causally increase ADHD risk.4

27. Neck / shoulder pain

One study found that gene variants correlated with neck or shoulder pain may causally increase ADHD risk.4

28. Colitis

One study found a 2.31-fold risk (OR) for ulcerative colitis in ADHD sufferers.50

It seems interesting to us in this context that colitis is often accompanied by strongly elevated levels of adenosine.20 Adenosine inhibits dopamine, especially in the striatum and other brain regions relevant to ADHD. In this respect, it would be at least theoretically conceivable that colitis could cause ADHD symptoms also through elevated levels of adenosine. For more on adenosine, see Adenosine In the chapter Neurological Aspects

29. Ankylosing Spondylitis / Bekhterev’s Disease

One study found ADHD sufferers to have a 2.78-fold risk (OR) of ankylosing spondylitis / ankylosing spondylitis.50

In this context, it seems interesting to us that ankylosing spondylitis is often associated with strongly increased expression of A2A and A3 adenosine receptors in lymphocytes.21

30. Ehlers-Danlos syndrome (EDS)

Ehlers-Danlos syndrome is a group of rare diseases of the connective tissue, which are associated with overstretchable skin, joints and ligaments
Of those with EDS, many suffer from psychiatric comorbidities:51

  • Speech disorders: 63.2 %
  • ADHD: 52.4 %
  • Anxiety: 51.2
  • Learning disorders: 42.4
  • Depression: 30.2 %

31. Ornithine transcarbamylase deficiency

Ornithine transcarbamylase deficiency52 occurs in approximately 1 / 30,000 people and is due to a genetic defect in the OTC gene. Residual enzyme gene mutations also exist, so they may not be diagnosed immediately. Affected individuals develop typical neuropsychological complications such as53

  • Developmental delay
  • Learning Disability
  • mental disability
  • Attention Deficit/Hyperactivity Disorder
  • Deficits in the executive function

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  14. Strom, Fishbein, Paller, Silverberg (2016): Association between atopic dermatitis and attention deficit hyperactivity disorder in U.S. children and adults. Br J Dermatol. 2016 Nov;175(5):920-929. doi: 10.1111/bjd.14697.

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