Problem of Adult ADHD Misdiagnosis in Armenian Psychiatric Service

Attention Deficit/Hyperactivity Disorder (ADHD) is one of the most common neurodevelopmental disorders affecting individuals throughout their lives. Despite increased awareness and a growing number of diagnosed clinical cases, ADHD diagnosis remains a subject of controversy. Recent studies have emphasized the key challenges in accurately diagnosing and differentiating ADHD, especially given the symptom overlap with psychiatric, neurological, and developmental conditions.

One of the primary concerns is the heterogeneity of symptoms and the lack of clear diagnostic tools and standardized procedures. ADHD is characterized by core symptoms of inattention, hyperactivity, and impulsivity. However, these symptoms often present differently across individuals and at various developmental stages. This variability complicates diagnosis, particularly in populations such as women, adults, and individuals with anxiety, mood disorders, or autism spectrum disorders. A 2023 meta-analytic study involving over 21 million adults estimated the average prevalence of ADHD at around 3.1%, with the inattentive subtype being the most common. This is a significant finding, as the inattentive subtype may go unnoticed for years, leading to unstable careers, personal difficulties, and the development of secondary mental health conditions such as depression or anxiety [1].

The overlap of diagnostic criteria between ADHD and other conditions – such as thyroid dysfunction, absence seizures, or sleep deprivation – can also lead to misdiagnosis. The comorbidity of psychiatric conditions remains another major challenge. ADHD is often accompanied by other psychiatric disorders such as depression, bipolar disorder, substance use disorders (SUD), and autism spectrum disorders. In adults especially, ADHD may go undiagnosed due to symptom masking or misattribution to mood disorders or SUD [2]. Furthermore, the presence of comorbidities frequently results in delayed diagnosis and poorer treatment outcomes, reinforcing the need for structured diagnostic assessments that account for functional impairments and longitudinal symptom trajectories.

Women often present with internalized symptoms – such as internal tension, distractibility, and hypersensitivity, which frequently lead to other diagnoses, such as depression or anxiety disorders [3]. As a result, many women begin to suspect they have ADHD only later in life, once challenges in managing everyday responsibilities become overwhelming.

A comprehensive systematic literature review [4] indicates that current diagnostic tools – both questionnaires and clinical interviews – have limited reliability and clarity when applied to adult ADHD. Many of these tools were developed for children and lack adequate adaptation to the adult life context.

Another key issue is the absence of functional impairment assessment. ADHD is not merely a cluster of symptoms; it significantly disrupts social, professional, and personal functioning. However, this aspect is often neglected in the diagnostic process. There is a need to develop new tools that specifically measure functional difficulties [5].

Qualitative research also highlights that many adults report confusion, frustration, and feelings of being undervalued during the diagnostic process. This reflects both structural issues in healthcare systems and gaps in specialist training [6].

At the same time, the field is facing concerns about overdiagnosis and widespread prescription of medication. The broadening of diagnostic criteria and increased public awareness of ADHD have raised fears that typical variations in attention and behavior may be pathologized. Some researchers argue that ADHD is partly a socially constructed condition, shaped by contextual factors such as school environments, cultural expectations, and healthcare access, which influence who and when gets diagnosed [7].

Finally, ADHD diagnosis in adults remains underdeveloped. Many adults retrospectively “identify” with ADHD symptoms but face barriers to receiving an official diagnosis due to the lack of childhood medical records or because symptoms are overlooked during clinical evaluation. Only 20–25% of adults with ADHD are correctly diagnosed globally. Among individuals previously evaluated for other psychiatric disorders, over 60% had symptoms consistent with undiagnosed ADHD [4, 8].

Over time, the manifestation of symptoms may shift – for example, hyperactivity may decrease, while executive dysfunction or internal restlessness persist – requiring diagnostic models that consider developmental trajectories [9].

In summary, diagnosing ADHD in the modern era involves a complex interplay of clinical, social, and systemic factors. Latest studies underscore the urgent need to improve diagnostic accuracy through better tools, broader conceptual frameworks, and integrated approaches that take into account comorbidities, functional impact, and lived experience across diverse social environments. Addressing these challenges is essential not only to reduce misdiagnosis but also to ensure timely and effective interventions for those affected.

METHODOLOGY

This study included a total of 83 patients (49 male, 34 female) with a confirmed diagnosis of ADHD. The average age of participants was 36.7 years. All individuals had previously sought psychiatric care and had undergone at least one psychiatric evaluation by another psychiatrist or psychiatric service prior to their inclusion in this study.

Each participant underwent a comprehensive diagnostic reassessment conducted by our team, which confirmed the presence of ADHD in all cases based on ICD-10 criteria. In addition to confirming the ADHD diagnosis, we conducted a clinical evaluation to identify and document any comorbid psychiatric or somatic conditions (if needed). Diagnostic conclusions were based on clinical interviews, patient history, and the review of previous medical records and psychiatric assessments.

No statistical analyses were performed, as the aim of the study was descriptive and exploratory. We performed a qualitative analysis of the patterns and content of prior diagnoses, with particular attention to frequent misdiagnoses and missed ADHD cases. The analysis focused on identifying potential contributing factors, including limited awareness or training of clinicians regarding adult ADHD, challenges in differential diagnosis, overlapping symptom presentations, and the structural or organizational format of psychiatric services previously accessed by patients.

RESULTS AND DUSCUSSION

As we can see in Table 1, absolute majority of people, diagnosed with ADHD during the current study, were not assessed as those during the previous psychiatric examinations. Instead, most of them were diagnosed or described with other psychiatric disorders, some of which were later confirmed and others refuted.

Anxiety and stress-related disorders

Generalized Anxiety Disorder (GAD) is a commonly overlapping condition with ADHD due to shared symptoms like restlessness, poor concentration, and sleep disturbances. Up to 47% of adults with ADHD meet criteria for an anxiety disorder [2]. GAD is particularly misdiagnosed instead of ADHD in ~30% of women with internalized symptoms [3]. The relatively high number of comorbidities in our study (11) supports that GAD was often a correct observation, though perhaps ADHD was missed or misattributed to anxiety alone in some cases. In 2 of these 10 cases diagnosis of GAD was not confirmed. We also have 11 cases described previously as “unspecified anxiety”. This is revealing that many previous clinicians noted “anxiety” informally, without sufficient diagnostic clarity or follow-up to confirm it. Only 3 of these people later got confirmed diagnosis of GAD.

Panic disorder is less frequently diagnosed officially, yet the high number of confirmed comorbidities suggests clinicians may have recognized anxiety symptoms (such as hyperarousal, palpitations) but did not formally code them. ADHD patients with high emotional reactivity may often present with panic symptoms, leading to misdiagnosis or underrecognition of both conditions.

Somatic symptoms (e.g., headaches, pain, fatigue, gastro-intestine complaints) are frequently observed in individuals with ADHD, often stress-related. The relatively low rate of official diagnosis but moderate comorbidity suggests somatic complaints may have been present but interpreted through a psychosomatic lens rather than as part of a neurodevelopmental picture. We observed particularly high comorbidity with Irritable bowel syndrome (IBS), which aligns with emerging evidence linking ADHD with functional gastrointestinal disorders. IBS may reflect stress reactivity, autonomic dysregulation, or impulsive eating habits. It’s notable that over 1 in 6 of your ADHD patients had confirmed IBS, emphasizing the need for integrated somatic-psychiatric care.

PTSD was relatively frequently diagnosed or suspected, which is plausible given the symptom overlap (hypervigilance, distractibility, irritability) and nationwide post-war consequences within the last 5 years. The high number of confirmed comorbidities (7) also implies that trauma is not uncommon among ADHD patients and may contribute to diagnostic overshadowing.

Although only 2 prior psychiatrists mentioned Complex PTSD (as no official ICD-10 code exists), our team confirmed it in 24 patients. This may reflect significant histories of chronic trauma, emotional neglect, or relational instability, which are highly prevalent and often missed in ADHD evaluations. It suggests a major gap in previous assessments regarding trauma-informed diagnosis, as many of those patients arrived with different other psychiatric diagnoses, and opens a wide space for further investigation.

In group of patients with OCD we had both over diagnosed and under diagnosed cases. 2 of 7 patients came with OCD diagnoses, were not confirmed as OCD. Misinterpretation of overfocused attention or hyperfixation (common in ADHD) may have contributed to incorrect OCD labeling, as it is known that OCD is misdiagnosed in up to 11–17% of ADHD patients, especially with hyperfocus [10]. True comorbidity rates are much lower: 1–3%. [11]. Symptoms of ADHD such as intrusive thoughts, restlessness, or perfectionistic tendencies can be mistaken for OCD, especially when patients describe mental rigidity or rituals. However, unlike in OCD, the intrusions in ADHD are often impulsive, unstructured, and not ego-dystonic. On the other hand, we confirmed OCD in another 5 patients, with 3 cases of contrast OCD, including two of those with homo-OCD subtype.

Affective disorders

Current findings show that up to 50% of adults with ADHD are initially diagnosed with depression instead [1], while lifetime prevalence of major depressive disorder in adults with ADHD was 18.6% compared to 7.8% (SE 0.4) in non-ADHD respondents [9]. Depressive symptoms like low motivation, concentration problems, fatigue, or irritability often mimic ADHD. Clinicians may have focused on these secondary symptoms and missed the primary diagnosis, particularly because ADHD symptoms were being interpreted as emotional distress rather than attentional or executive dysfunction if the history of lifelong inattention or hyperactivity wasn’t explored.

It may seem that vague label of unspecified depression suggests clinical uncertainty, but objectively in most cases it was determined by unnecessity to confirm official diagnosis and reflects a tendency to code affective disturbance without a full diagnostic formulation in cases where there is no need to do it by legal or statistical reasons.

In two patients, we observed misdiagnosis of Bipolar disorder. Impulsivity, mood swings, emotional outbursts, and variable energy - core ADHD features - can mimic hypomania or cycling moods, especially in adolescents or young adults. 20%+ of ADHD patients are misdiagnosed with bipolar disorder, especially in adolescence [4]. Up to 21.2% of individuals with bipolar disorder also meet ADHD criteria [12]. This often leads to false bipolar diagnoses, especially in the absence of clear manic episode. Clinicians may have interpreted dysregulated affect through a mood disorder framework instead of a neurodevelopmental one.

Addiction disorders

Cannabis-related disorders were expectedly one of two most common addiction disorders observed in patients with ADHD in our study. Overall, 25–34% of adults with ADHD have a lifetime substance use disorder [2]. In particular, Cannabis use disorder is 2–5 times more likely among those with ADHD [13]. This diagnosis may reflect self-medication behavior in ADHD patients attempting to manage restlessness, insomnia, or emotional dysregulation. Clinicians may have focused on the substance use without identifying the underlying ADHD. Misdiagnosis can occur when the behavioral consequences of ADHD are treated as primary addictive pathology, rather than symptoms of a broader regulatory disorder.

As with cannabis, alcohol use may represent a maladaptive coping strategy rather than an independent disorder. Emotional impulsivity, frustration intolerance, and poor self-regulation can increase the likelihood of alcohol misuse. These cases suggest that substance-related presentations may have obscured the core neurodevelopmental condition in previous assessments. As many people with mild to moderate alcohol addiction doesn’t report this condition as problematic, only 2 of 6 lately confirmed people were previously evaluated as addicted.

Gambling behavior in ADHD patients may arise from novelty-seeking, risk-taking, or reward sensitivity. Without recognizing these as manifestations of dopamine dysregulation common in ADHD, clinicians may have diagnosed pathological gambling as a standalone impulse-control issue. The high number of prior informal mentions suggests that such behaviors were frequently seen, yet misinterpreted outside of the ADHD framework.

Personality Disorders

Borderline Personality Disorder. Comorbidity of ADHD and BPD ranges from 18–34% [14]. Emotional instability, impulsive relationships, and intense affect are shared traits between ADHD and borderline personality disorder. Without close attention to developmental history, clinicians may interpret the emotional dysregulation of ADHD as a personality pathology. The strong presence of this label highlights a common diagnostic confusion, particularly in women with undiagnosed ADHD [3]. However, most recent studies show not only comorbidity, but interconnection of these two diagnoses [15].

Schizoid Personality Disorder. Social withdrawal or inattentiveness in ADHD – especially in inattentive-type presentations - can resemble the flattened interpersonal engagement seen in schizoid traits. This rare misdiagnosis suggests a misunderstanding of socially avoidant behavior that is more likely due to overstimulation, fatigue, or executive overload rather than true emotional detachment.

Obsessive-Compulsive Personality Disorder. ADHD individuals who rely on rigid routines or overcontrol to compensate for executive dysfunction may appear perfectionistic or controlling. Such coping styles, especially when compensating for chronic disorganization, can mimic OCPD. This misinterpretation emphasizes the need to differentiate between compensatory behavior and enduring personality structure.

Avoidant Personality Disorder. Avoidance behaviors in ADHD may stem from chronic failure experiences, low self-esteem, or sensory overwhelm. When this is misread as a pervasive personality trait rather than a consequence of untreated symptoms, avoidant personality disorder may be incorrectly assigned. This highlights the psychosocial consequences of undiagnosed ADHD.

Narcissistic Personality Disorder. Impulsivity, self-centered talk, or exaggerated emotions in ADHD can sometimes be misread as narcissistic traits, especially in emotionally labile presentations. However, these are typically not rooted in a grandiose or exploitative personality style. Previous clinicians may have overemphasized surface behavior without assessing the deeper motivational and cognitive structure.

Neurodevelopmental disorders

According to Antshel et al., 15-20 % of people with ADHD demonstrate ASD symptoms [16]. Only few cases in our selection were previously labeled as classic autism, likely due to social difficulties, rigid interests, or sensory sensitivities – traits which can overlap with ADHD. However, ADHD social traits tend to result from impulsivity and inattention, rather than fundamental deficits in reciprocity or communication. Misdiagnosis may have stemmed from an overemphasis on external behaviors without deeper developmental profiling.

Another group of patients (4 people) were suspected to have ASD without receiving formal diagnosis. Many of these were likely exhibiting ADHD-associated traits like sensory defensiveness, hyperfocus, or difficulty with social nuance. ADHD and ASD comorbidity is reported in 20–50% of cases, especially in childhood [17]. Without comprehensive differential diagnosis, such traits can easily be misattributed to autism, especially under the broadened “spectrum” conceptualization. However, we observed different amount of autistic spectrum traits in significantly bigger number of patients, though in most cases they need further more detailed examination for diagnostic clarification.

The most worrying part of investigation was that only in 15 total cases ADHD was previously seen by psychiatrists. This indicates a huge systemic underdiagnosis or diagnostic hesitation – possibly due to a focus on surface-level symptoms like anxiety or mood disturbances, low level of awareness, or inappropriate developmental history collection. Below we discuss the possible reasons of this severe gap.

Other mental disorders

Schizotypal disorder. It’s notable to mention the case of misdiagnosis with Schizotypal disorder, which is relatively common in people with ADHD struggling to adopt in society, because of misinterpretation of social awkwardness, tangential thinking, or sensory sensitivities. In our case, selective social isolation leading to suspiciousness, intense internal thought processes, impulsivity and eccentric behavior have been pathologized as psychotic traits, while the developmental context was overlooked.

Personality Disorder Due to Known Physiological Condition. This diagnosis suggests prior psychiatrists perceived organic or post-traumatic brain dysfunction behind behavioral symptoms. In ADHD, executive dysfunction may mimic frontal syndrome traits such as impulsivity, irritability, or social disinhibition. The misattribution to “organic personality change” rather than a lifelong attentional disorder indicates a tendency to over-pathologize the behavioral expression without developmental anchoring. There is also often reported and consistent tendency to refer to “organic brain damage” many conditions expressed by unclear or ambiguous symptoms in case of past head injuries in anamnesis, regardless of how much the effects of the injury have been confirmed by relevant studies.

Eating Disorders. ADHD often coexists with disordered eating due to impulsivity, emotional eating, or sensory processing differences. However, when clinicians see these symptoms in isolation - particularly binge eating or chaotic food behavior – they may diagnose an eating disorder without linking it to attentional regulation or emotional instability. Up to 27% of individuals with binge eating disorder meet ADHD criteria [18], but there is also data that Bulimia nervosa often misdiagnosed in impulsive-type ADHD presentations [19]. This reinforces the need for integrated assessment of appetite control, emotion regulation, and attention. In our sample, 3 of 8 patients reported previously as ones with eating disorder, were unofficially diagnosed with bulimia nervosa, and 5 – as binge eaters. After our evaluation, all of them, as well as 5 other patients without previously recognized eating behavior troubles, were evaluated as binge eating disorder.

Type 2 Diabetes Mellitus. The notable presence of type 2 diabetes suggests the long-term health impact of ADHD-associated lifestyle factors: poor planning, irregular eating, low physical activity, and impulsive consumption patterns. This somatic comorbidity reflects not a diagnostic error, but the need for multidisciplinary awareness of ADHD’s influence on physical health outcomes.

Trends of ADHD diagnosis in psychiatric services

In addition, we conducted survey among 20 psychiatrists, working in 3 main psychiatric service types: inpatient unit in state clinics, outpatient unit in state clinics and private outpatient clinics.

Since in many cases it is extremely difficult for specialists to provide precise numbers regarding diagnosed cases, we have included approximate figures intended to reflect general trends. Diagnosed cases are considered those in which the ICD-10 criteria were applied accurately and the diagnosis was documented in the medical history or consultation report as a primary or secondary diagnosis. We have also separately included information on cases where the ADHD diagnosis was made with a significant delay – identified only after the person had been working for at least three months.

The data shows that ADHD diagnoses are unproportionally rare in state psychiatric services, especially in inpatient settings. Most entries for primary ADHD diagnosis in these services report zero cases, with only two psychiatrists performed with between 1 to 5 diagnoses. Secondary ADHD diagnoses are slightly more frequent but still limited, and late ADHD diagnoses are uncommon. The use of standardized ADHD questionnaires in state services is almost nonexistent, appearing only once as “sometimes”. This pattern suggests that state services generally lack training, resources, or focus on ADHD, and do not prioritize its identification, particularly as a primary diagnosis.

In contrast, specialists in private outpatient services report significantly higher numbers of ADHD diagnoses. Several such specialists indicate over 20 cases of both primary and secondary ADHD diagnoses annually, with some also noting 5 to 10 late diagnoses. ADHD questionnaires are used more frequently here, with some marking their usage as “always” or “sometimes.” This indicates that private services are more proactive in recognizing and diagnosing ADHD, likely due to better clinician awareness, access to diagnostic tools, and a client population that expects or demands comprehensive assessments.

The data also shows a clear disparity between state and private services. ADHD diagnosis appears to be dependent on the type of service accessed, with public sector patients being at risk of underdiagnosis. This may stem from the public sector’s focus on more severe psychiatric conditions, resource limitations, or insufficient clinician training regarding ADHD. Outpatient services, particularly private ones, are also more likely to recognize ADHD as a secondary diagnosis or identify it later in the patient’s clinical course, which implies better longitudinal follow-up and greater attention to developmental or behavioral signs.

A consistent pattern emerges linking the use of ADHD questionnaires with higher diagnosis rates. Every service that uses questionnaires frequently reports significantly more diagnoses. In contrast, services that do not use them almost universally report zero or minimal diagnosis rates. This strongly suggests that the availability and use of standardized diagnostic tools are critical for identifying ADHD.

Overall, the table reflects major systemic gaps in ADHD diagnosis, with private outpatient services leading in recognition and state services lagging significantly. The findings highlight the need for increased awareness, professional training, and the standardized use of diagnostic tools in all psychiatric settings, particularly within the public sector.

CONCLUSION

The findings of our study highlight the significant psychopathological complexities involved in the accurate diagnosis of ADHD in adults. ADHD often presents with a broad spectrum of symptoms, ranging from inattention and emotional dysregulation to impulsivity and restlessness that overlap with various psychiatric conditions such as anxiety disorders, depression, bipolar disorder, personality disorders, autism spectrum disorders etc. This symptom overlap, along with developmental variability, frequently leads to diagnostic confusion. Internalized symptoms, executive dysfunction, or coping strategies that mask core ADHD features further complicate the clinical picture, causing the disorder to be misdiagnosed or entirely overlooked in many individuals. Additionally, comorbid conditions may overshadow or mimic ADHD symptoms, contributing to significant delays in recognition and appropriate intervention.

Beyond the psychopathological challenges, it is necessary to mention systemic and structural factors contributing to the frequent misdiagnosis or underdiagnosis of adult ADHD in Armenia. One of the core issues is the low level of awareness and training among mental health professionals, as ADHD remains largely outside the focus of mainstream psychiatric education and public discourse until the last few years. This lack of focus is compounded by the absence of Armenian language diagnostic guidelines, protocols, and standardized tools adapted to adult populations, leaving clinicians without reliable frameworks for assessment. Furthermore, the type and structure of psychiatric services significantly influence diagnostic priorities. In crisis-oriented and medication-focused services, the diagnostic process may be shaped by immediate treatment goals rather than longitudinal or developmental understanding. This often results in an overemphasis on mood or behavioral symptoms at the expense of identifying ADHD as the underlying condition. Along with this, private outpatient services with more advanced approaches and resources usually are not available for most of population.

Another critical issue is the disconnect between child/adolescent and adult mental health services, which prevents smooth diagnostic continuity across the lifespan. Many individuals lose contact with services during adolescence and are never reassessed for ADHD in adulthood, even when symptoms persist or evolve. Additionally, fragmentation between general and specialized services, lack of interdisciplinary collaboration, and limited mental health resources outside urban centers further hinder timely diagnosis.

Addressing these challenges requires a multidimensional strategy: raising professional and public awareness, integrating ADHD into clinical training curricula, developing national guidelines and diagnostic tools tailored for adult populations, and ensuring service continuity across age groups. Moreover, incorporating functional assessments and lived experience perspectives into diagnostic procedures could lead to more accurate identification and earlier intervention, ultimately improving long-term outcomes for individuals with ADHD.

Table 1. Previous diagnoses and clinical evaluations of people later diagnosed with ADHD.

Table 2. ADHD diagnostics trends in different types of psychiatric service.

References

1. Ayano G, Tsegay L, Gizachew Y et al. Corrigendum to ‘Prevalence of attention deficit hyperactivity disorder in adults: Umbrella review of evidence generated across the globe’ [Psychiatry Research 328 (2023) 115449]. Psychiatry Res. 2023;330:115578.
2. van Emmerik-van Oortmerssen K, van de Glind G, van den Brink W et al. Prevalence of attention-deficit hyperactivity disorder in substance use disorder patients: a meta-analysis and meta-regression analysis. Drug Alcohol Depend. 2012;122(1-2):11-19.
3. Attoe DE, Climie EA. Miss. Diagnosis: A Systematic Review of ADHD in Adult Women. J Atten Disord. 2023;27(7):645-657.
4. Weibel S, Menard O, Ionita A et al. Practical considerations for the evaluation and management of Attention Deficit Hyperactivity Disorder (ADHD) in adults. Encephale. 2020;46(1):30-40.
5. Fuermaier ABM, Gontijo-Santos Lima C, Tucha O. Impairment Assessment in Adult ADHD and Related Disorders: Current Opinions From Clinic and Research. J Atten Disord. 2024;28(12):1529-1541.
6. Abdelaziz S, Garfield S, Neves AL et al. What are the unintended patient safety consequences of healthcare technologies? A qualitative study among patients, carers and healthcare providers. BMJ Open. 2024;14(11):e089026.
7. Koutsoklenis A, Honkasilta J. ADHD in the DSM-5-TR: What has changed and what has not. Front Psychiatry. 2023;13:1064141.
8. Rivas-Vazquez RA, Diaz SG, Visser MM, Rivas-Vazquez AA. Adult ADHD: Underdiagnosis of a Treatable Condition. J Health Serv Psychol. 2023;49(1):11-19.
9. Kessler RC, Adler L, Barkley R et al. The prevalence and correlates of Adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163:716–723.
10. Abramovitch A, Dar R, Mittelman A, Wilhelm S. Comorbidity between attention deficit/hyperactivity disorder and obsessive-compulsive disorder across the lifespan: a systematic and critical review. Harv Rev Psychiatry. 2015;23(4):245-262.
11. Harrison AG, Edwards MJ. The ability of self-report methods to accurately diagnose attention deficit hyperactivity disorder: a systematic review. J Atten Disord. 2023;27(12):1343-1359.
12. Nierenberg AA, Miyahara S, Spencer T et al. Clinical and diagnostic implications of lifetime attention-deficit/hyperactivity disorder comorbidity in adults with bipolar disorder: data from the first 1000 STEP-BD participants. Biol Psychiatry. 2005;57(11):1467-1473.
13. Bidwell LC, Henry EA, Willcutt EG, Kinnear MK, Ito TA. Childhood and current ADHD symptom dimensions are associated with more severe cannabis outcomes in college students. Drug Alcohol Depend. 2014;135:88-94. 
14. Philipsen A, Limberger MF, Lieb K et al. Attention-deficit hyperactivity disorder as a potentially aggravating factor in borderline personality disorder. Br J Psychiatry. 2008;192(2):118-123.
15. Rüfenacht E, Pham E, Nicastro R et al. Link between history of childhood maltreatment and emotion dysregulation in adults suffering from attention deficit/hyperactivity disorder or borderline personality disorder. Biomedicines. 2021;9(10):1469.
16. Antshel KM, Zhang-James Y, Wagner KE, Ledesma A, Faraone SV. An update on the comorbidity of ADHD and ASD: a focus on clinical management. Expert Rev Neurother. 2016;16(3):279-293.
17. Leitner Y. The co-occurrence of autism and attention deficit hyperactivity disorder in children – what do we know? Front Hum Neurosci. 2014;8:268.
18. Levin RL, Rawana JS. Attention-deficit/hyperactivity disorder and eating disorders across the lifespan: A systematic review of the literature. Clin Psychol Rev. 2016;50:22-36. 
19. Biederman J, Ball SW, Monuteaux MC et al. Are girls with ADHD at risk for eating disorders? Results from a controlled, five-year prospective study. J Dev Behav Pediatr. 2007;28(4):302-7.