How should we manage a 21-year-old woman with binge‑eating disorder, attention‑deficit/hyperactivity disorder, social anxiety disorder, and a possible history of obsessive‑compulsive disorder?

Management of a 21-Year-Old Woman with Binge-Eating Disorder, ADHD, Social Anxiety Disorder, and Possible OCD

Immediate Diagnostic Clarification

Begin with structured assessment to confirm or rule out OCD, as this fundamentally alters your treatment algorithm. 1

• Administer the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) to quantify OCD severity; scores ≥14 indicate clinically significant OCD requiring specific treatment. 1, 2
• Distinguish childhood OCD history from current symptoms by asking: "Are intrusive thoughts currently present, unwanted, and causing marked distress that you actively try to suppress?" versus "Do you have rigid routines that feel comfortable and part of your identity?" 2
• If current OCD is confirmed, assess whether obsessions are ego-dystonic (anxiety-provoking, unwanted) pointing to active OCD, or whether childhood symptoms have resolved. 1, 2
• Screen for reassurance-seeking behaviors, mental rituals (counting, repeating words silently), and time spent on obsessions/compulsions (>1 hour daily indicates clinical significance). 1, 2

First-Line Pharmacological Treatment

Initiate lisdexamfetamine 30 mg daily, which is FDA-approved for binge-eating disorder and simultaneously treats ADHD, with the added benefit of reducing obsessive-compulsive symptoms if OCD is present. 1, 3

• Lisdexamfetamine is the only FDA-approved medication for binge-eating disorder and demonstrates significant reduction in binge episodes while improving obsessive-compulsive symptoms. 1
• This medication achieves approximately 70% response rate for ADHD symptoms and commonly produces secondary reductions in anxiety symptoms, making it ideal for this comorbidity profile. 4
• Titrate to 50-70 mg daily over 4-6 weeks to achieve maximal therapeutic benefit for both binge eating and ADHD. 1, 3
• Alternative if lisdexamfetamine is unavailable: methylphenidate extended-release starting at 18-36 mg daily, which has demonstrated efficacy in reducing both ADHD and binge eating episodes, plus improvement in obsessive-compulsive symptoms. 1, 5

If OCD is confirmed as active and moderate-to-severe, add an SSRI at higher-than-depression doses simultaneously with the stimulant. 1, 6

• Initiate sertraline 50 mg daily or fluoxetine 20 mg daily (both FDA-approved for OCD). 1, 6
• Titrate sertraline to 150-200 mg daily or fluoxetine to 40-80 mg daily over 4-6 weeks; OCD requires higher doses than depression or anxiety disorders. 1, 6
• Maintain SSRI for minimum 8-12 weeks at maximum tolerated dose before declaring treatment failure. 1, 6
• SSRIs also treat social anxiety disorder effectively, addressing two conditions with one medication. 1

Cognitive-Behavioral Therapy Protocol

Initiate 10-20 sessions of individual CBT with exposure and response prevention (ERP) targeting all three conditions simultaneously using an integrated approach. 1, 7

• For binge eating: Implement ERP strategies targeting eating pathology, including exposure to feared foods, response prevention of binge episodes, and supervised eating plans. 7
• For OCD (if confirmed): Conduct graded exposure to feared stimuli while intentionally resisting compulsions, using the downward arrow technique to identify core fears. 1, 6
• For social anxiety: Incorporate exposure hierarchies to social situations with response prevention of avoidance and safety behaviors. 1
• Evidence demonstrates that simultaneous treatment of multiple conditions using integrated ERP is effective and superior to sequential treatment. 7

For ADHD-specific behavioral interventions, implement dialectical behavior therapy (DBT) modules adapted for ADHD. 1

• Mindfulness skills module addresses poor concentration. 1
• Distress tolerance module addresses disorganization and impulsivity contributing to binge eating. 1
• Interpersonal effectiveness skills module addresses social anxiety and troubled relationships. 1
• Emotion regulation module addresses affective lability common in ADHD. 1

Treatment Sequencing Algorithm

1. Week 1-2: Start lisdexamfetamine 30 mg daily; if active OCD confirmed, add sertraline 50 mg daily simultaneously. 1, 6, 3
2. Week 2-4: Titrate lisdexamfetamine to 50 mg daily and sertraline (if prescribed) to 100 mg daily. 1, 6
3. Week 4-6: Reach target doses (lisdexamfetamine 50-70 mg, sertraline 150-200 mg if prescribed). 1, 6
4. Week 2 onward: Begin weekly CBT with integrated ERP for binge eating, OCD (if present), and social anxiety. 1, 7
5. Week 8-12: Assess response; if inadequate, consider adding topiramate 25-50 mg daily (titrate to 100-200 mg) for binge eating augmentation. 1, 3

Mandatory Comorbidity Screening

Screen for depression, substance use disorders, bipolar disorder, and suicidal ideation at baseline and throughout treatment. 1, 4

• Depression occurs in approximately 9% of ADHD patients and requires assessment before initiating stimulants. 4
• Bipolar disorder is a critical differential; stimulants can precipitate manic episodes and require mood stabilization first. 1
• Substance use disorders are elevated in ADHD; screen at baseline and monitor throughout treatment. 4
• Assess suicidal ideation given the comorbidity burden; untreated ADHD increases suicide risk. 4

Chronic Care Management

Manage this patient following chronic care model principles with ongoing monitoring for symptom changes and emergence of new comorbidities. 4

• Schedule monthly follow-ups for the first 3 months, then every 2-3 months once stable. 4
• Monitor for stimulant misuse risk, though less concerning at age 21 than in adolescence. 4
• Continue SSRI (if prescribed) for 12-24 months after remission due to high OCD relapse risk. 1, 6
• Maintain monthly CBT booster sessions for 3-6 months after acute treatment phase. 1

Critical Pitfalls to Avoid

• Never withhold stimulants due to anxiety concerns; evidence demonstrates stimulants frequently improve anxiety symptoms and are well-tolerated in patients with comorbid anxiety disorders. 4
• Never use depression-level SSRI doses for OCD (e.g., sertraline 50 mg); this represents inadequate treatment and will fail. 1, 6
• Never declare treatment failure before 8-12 weeks at maximum tolerated doses; premature switching undermines evidence-based care. 1, 6
• Never treat conditions sequentially when integrated treatment is available; simultaneous treatment of binge eating and OCD using combined ERP is superior to treating one condition at a time. 7
• Never prescribe atypical antipsychotics (olanzapine, clozapine), mirtazapine, or valproate in this patient; these cause significant weight gain and will worsen binge eating disorder. 3
• Never misdiagnose binge eating as simple obesity or lack of willpower; this is a psychiatric disorder requiring specific pharmacotherapy and psychotherapy. 1, 3

Monitoring Parameters

• Weekly weight and binge episode frequency for first 8 weeks. 7
• Y-BOCS scores monthly if OCD confirmed (target reduction to <14). 1, 2
• ADHD symptom severity using standardized scales (ASRS) monthly. 1
• Social anxiety symptoms using validated measures (e.g., Social Phobia Inventory) monthly. 1
• Stimulant side effects: heart rate, blood pressure, sleep, appetite at each visit. 1, 4
• Emergence of depressive symptoms or suicidal ideation at each visit. 4

Expected Outcomes

• Binge eating episodes should decrease by 50% or more within 8-12 weeks on lisdexamfetamine. 1, 3
• ADHD symptoms should improve within 2-4 weeks of reaching therapeutic stimulant dose. 4, 5
• OCD symptoms (if present) should show 25-35% reduction in Y-BOCS scores after 8-12 weeks of adequate SSRI dosing plus CBT. 1, 6
• Social anxiety should improve with combined SSRI and exposure therapy over 12-16 weeks. 1
• Case reports demonstrate that methylphenidate in ADHD patients with comorbid OCD improved both ADHD and obsessive-compulsive symptoms significantly. 5