James Greenblatt, MD Chief Medical Officer, Walden Behavioral Care
ADHD and Eating Disorders
CHADD CONFERENCE November 10th
Atlanta
Disordered Eating
DISORDERED EATING
SHAME
GUILT
Cathy
The Evolution of ADHD
Defective Moral Control (1902)
Restlessness Syndrome (1920s)
Post-Encephalitic Behavior Disorder (1920s-1930s)
Brain Injured Child (1940s)
Minimal Brain Damage (1950s)
Minimal Brain Dysfunction (1960s–1970s)
Hyperactive Child Syndrome or Hyperkinetic Reaction of Childhood
(1960s)
Attention Deficit Disorder with or without Hyperactivity (1980)
Attention Deficit Hyperactivity Disorder & Undifferentiated Attention
Deficit Disorder (1987)
Attention Deficit Hyperactivity Disorder & Attention Deficit Disorder
(1993)
ADHD (2013) – DSM V
Brain Injured Child (1940s)
Minimal Brain Damage (1950s)
Minimal Brain Dysfunction
(1960s–1970s)
2017
14th Century
Evolution of Anorexia Nervosa
Catherine of Siena practiced an extreme form of
fasting and eventually died of starvation
Sir William W. Gull names the illness anorexia
nervosa – which means “nervous loss of appetite.”
Charles Lasègue, without the knowledge of Gull’s
work, described the condition as “L’anorexic
hysterique.”
John Berkman: “Among adolescents the cause for
the psychic upset can often be traced to a parent.”
Hilde Bruch’s psychological or cultural factors
1868
1870
1973
1947
Diary of a Young Psychiatrist
DRUGS! NO
DRUGS!
New Career
You don’t
see
what I
see!
ADHD: The Facts
Inattention – poor persistence of effort
Impulsivity
Hyperactivity – Cognitive Vs. Behavioral
Variability in performance
Difficulty with rule-governed behavior
Greater than 30% of patients with AN become
chronically ill over 10 years
Mortality rates: 10% at 10 years, 20% at 20
years!
Highest risk for suicide among all psychiatric
illnesses
Highest number of hospital days
Stress
Eating Disorders: The Facts
Treatment Fatigue
BED: Most Common ED in U.S. Adults
Bulimia Nervosa &
Anorexia Nervosa
Combined
Binge Eating
Disorder
DSM-5 Diagnostic Criteria for BED
Recurrent episodes of binge eating characterized by both of the following: Consuming an abnormally large amount of food in a short period of time compared with what others
might eat in the same amount of time under same or similar circumstances
Experiencing a loss of control over eating during the episode
Episodes feature at least 3 of the following Consuming food faster than normal
Consuming food until uncomfortable full
Consuming large amounts of food when not hungry
Consuming food alone due to embarrassment
Feeling disgusted, depressed, or guilt after the binge
Overall, there is significant distress about the binge eating
The binge eating occurs, on average, at least once per week for 3 months
The binge eating is not associated with regular compensatory behavior associated
with bulimia nervosa and does not occur solely during an episode of bulimia
nervosa or anorexia nervosa
Comorbidity
• Depression
• Anxiety
• OCD
• ADHD
• Bipolar disorder
• Personality
disorders
• Substance use
disorders
Up to 95% of ED patients suffer
from psychiatric comorbidity
Hudson. Biol Psychiatry. 2007 Feb 1;61(3):348-58.
Comorbidity is related to
treatment dropout
ADHD and Eating Disorders
2016 meta-analysis of 12 studies assessing
ED in ADHD populations and 5 studies
assessing ADHD in ED populations
Individuals with ADHD were 3.8x more
likely to have an ED diagnosis
Individuals with an ED were 2.8x more
likely to have an ADHD diagnosis
Nazar. Int J Eat Disord. 2016 Dec;49(12):1045-1057.
ADHD and Disordered Eating
1Surman CB et al. J Clin Psychiatry 2006;67(3):351-4. 2Castellanos FX et al. Biol Psychiatry 2013;e1731-e1738. 3Altfas JR. BMC Psychiatry 2002;2:9.
12% prevalence of ADHD in women
with bulimia compared to a 0-2%
percent prevalence in a control group1
Men who were diagnosed as children
with ADHD were twice as likely to be
obese in a 33-year follow up study2
Study of 215 patients in treatment for
obesity found that 27.4% of
participants had ADHD. Among those
with extreme obesity: 42.6%3
ADHD and Eating Disorders
Review of 37 studies looking at ADHD and eating
disorders across the lifespan
“The systematic review findings suggest
that children with ADHD are at risk for
disordered eating, while adolescents,
emerging adults, and adults are at risk
for both eating disorders and disordered
eating”
Levin & Rawana. Clin Psychol Rev. 2016 Dec;50:22-36.
Impulsivity
Five-year longitudinal study on girls with ADHD aged 6-12 years
Children with ADHD-combined type demonstrated more bulimia symptoms at follow-up than those without ADHD
Impulsivity was the strongest predictor of eating disorder
behavior
Mikami. J Abnorm Psychol. 2008 Feb;117(1):225-35.
Impulsivity
Patients with both an eating disorder
and ADHD have more impulsive traits
than patients with either condition alone
2017 review of 75 studies on the
association between ADHD
symptomatology and disordered eating
behavior concluded:
Kaisari. Clin Psychol Rev. 2017 Apr;53:109-121.
There is consistent evidence
that impulsivity symptoms of
ADHD are positively
associated with overeating
and bulimia nervosa
ADHD is a Risk Factor for Obesity
6,934 children from the Northern Finland Birth Cohort
ADHD symptoms at age 7 to 8 years significantly predicted
obesity at age 16
Children with inattention and hyperactivity symptoms at age
8 were 90% more likely to have obesity as a teen
Childhood ADHD symptoms predicted physical inactivity in
adolescence
Khalife. J Am Acad Child Adolesc Psychiatry. 2014 Apr;53(4):425-36.
ADHD and Obesity Statistics
25% of treatment-seeking obese adults meet criteria for
ADHD, with a higher prevalence in the most obese
Reinblatt. Curr Treat Options Psychiatry. 2015 Dec;2(4):402-412.
Up to 50% of youths treated for overweight have ADHD
A 33 year old study found males with ADHD were 2x more likely to be obese at follow-up than controls
Neural Correlates of Food Behaviors
Examination of the neural correlates of
addictive-like eating behavior
Forty-eight healthy young women
ranging from lean to obese recruited
for a healthy weight maintenance trial
Elevated activation in reward
circuitry in response to food cues
and reduced activation of inhibitory
regions in response to food intake
Arch Gen Psychiatry. 2011;68(8):808-816.
Disordered Eating
Bulimia – Binge Eating Disorder – Obesity
Driving force is not that we
are choosing to binge,
rather our bodies are
unable to regulate appetite
and asking us to eat more
A diverse range of physiologically
generated eating behaviors
Consuming sufficient food for energy metabolism is
essential for the survival of all species in the animal
kingdom.
Mammalian brains have evolved several interrelated
neural and biochemical systems that drive feeding
behaviors.
The most potent drive for
feeding behavior is its
rewarding nature
The Facts
Binge eaters and those with disordered eating
experience physical cravings that are physiologically
based, rather than socially or environmentally based.
The Theory
Neurobiological Mechanisms of Addiction
Phase 1: Binge/Intoxication
Phase 2: Withdrawal/negative effect
Phase 3: Preoccupation/cravings
“ Dopamine made me do it ”
Obesity and the Brain
A 2010 study found that the BMI of adolescent
females was positively correlated with abnormal
patterns and levels of activation in brain areas
known to be involved in reward processing
The higher the BMI, the higher the level of brain
activation observed in these girls, who were tested
by being shown pictures of appetizing food after a
4-6 hour fast
Stice. Neuroimage. 2010 May 1;50(4):1618-25.
Obesity and the Brain
Obese individuals are hyper-responsive
to food stimuli and show less reduction
of activation of reward regions after
eating
The dopaminergic reward
system is key in explaining
the comorbidity of obesity
and ADHD
Finally Focused
Is there a need to get
something?
Is there a need to avoid
something?
Nutrients
Vitamins
Minerals
Fatty acids
Amino acids
Hormones
Light
Love
Nature
Positive Feedback
Allergens
Food
Pollen
Dust
Dander
Chemicals
Mold
Germs
Toxins
Elementary
(lead, mercury, etc.)
Biologic
(plants, germs, etc.)
Synthetic
(mostly
petrochemical)
Pesticides
Autoimmune
Celiac Disease
Medications
ADHD and Eating Disorders
Integrative treatments include:
PLUS
Omega-3 Supplementation
Neurofeedback
Medications
MINUS
Sugar
MSG
Sugar Addiction
Pleasure Centers in the Brain
Sweet sensations conveyed to the center
of the brain
Taste bud receptors
GI receptors
Stimulates release of dopamine
Sex and narcotics activate same
pleasure centers
Animal Studies
Rats love sugar water and will drink as much as offered
Release of dopamine initially
DA receptors become exhausted and over time starts to
decrease in number
Rats must ingest more sugar to get the same DA response
Features of Addiction:
Withdrawal of sugar: shaky, teeth chattering, tremors, agitation, and
hyperactivity
Binge Eating Disorder
40 day sugar diet: Decreased DA receptors and increased
food intake and obesity
Chronic sugar intake causes addiction like symptoms in
animals affecting regulation of food intake
Sugar-Sweetened Beverages
The amount of sugar-sweetened beverages consumed by
U.S. youth has nearly doubled since the 1970’s
Two-thirds of children aged 2-19 consume at least one
sugar-sweetened beverage on a given day
30% have two or more sugary drinks a day
Linked to SSBs:
weight gain
type 2 diabetes
kidney disease
cardiovascular
problems
Rosinger. NCHS Data Brief. 2017 Jan;(271):1-8.
Children in the top quintile of
“sweet” dietary pattern
(ice cream, refined grains,
sweet desserts, sugar, soft
drinks) score had almost 4x
the odds of having ADHD
compared with those in the
lowest quintile
Azadbakht & Esmaillzadeh. Nutrition. 2012 Mar;28(3):242-9.
High Sugar Diet and ADHD Risk
375 children, mean age 8 years
Sugar-Sweetened Beverages
Suglia. J Pediatr. 2013 Nov;163(5):1323-8.
In a national sample of nearly 3,000 5-year-
olds, 43% consumed at least 1 serving of
soda per day, and 4% consumed 4+ a day
Soda consumption was associated with
higher aggression on the Child Behavior
Checklist in a dose-response pattern
Children who consumed the most soda
had the most attention problems
1,649 middle schoolers
reported quantity and types of
sweetened beverages
consumed in the past 24 hours
Risk of hyperactivity /
inattention increased by 14%
for each additional
sweetened beverage
consumed
Sugar-Sweetened Beverages
Schwartz. Acad Pediatr.
2015 May-Jun;15(3):297-
304.
Refined sugars such as sucrose and high fructose corn
syrup can cause addiction like symptoms and can affect the
ability to control food intake
Sugar addiction may play a role in Binge Eating Disorder
and Obesity
Physiologically Generated Food Behaviors
ADHD
Vulnerability?
Food Addictions in the Church
“Sugared spices are
nonetheless not eaten with the
end in mind of
nourishment, but rather for
ease in digestion; accordingly,
they do not break the fast any
more than the taking of any
other medicine.”
— St. Thomas Aquinas (1225-1274)
Catholic priest and theologian
Taste Buds Hijacked
What is Monosodium Glutamate?
Monosodium Glutamate (MSG)
is a toxic food additive that
causes the brain to think that the
food has more protein and tastes
better.
MSG is approximately 78% free
glutamic acid, 21% sodium, and
1% contaminants.
MSG is Everywhere
MSG Causes Disordered Appetite
MSG consumption causes resistance to
the hormone leptin
Leptin resistance means that the brain
cannot properly “hear” the messages
the leptin sends it and will therefore
continue to be hungry and store fat
Physiologically Generated Eating
Behaviors
MSG can cause addiction like symptoms and can affect the
ability to control one’s food intake
MSG may play a role in Binge Eating Disorder and Obesity
Sugar
MSG can cause
addiction like symptoms
and can affect the ability
to control food intake
Physiologically Generated Food Addiction
ADHD
Vulnerability
Fats of Life
Essential Fatty Acids And Cholesterol in
Neurotransmission
Synthesis
Degradation
Release
Re-uptake
Binding
NO FATS?
Cultural Chaos
Omega-3 Fatty Acids
Every aspect of
neurotransmission involves adequate
functioning of omega 3s.
Essential Fatty
Acid Deficiency Anxiety
Depression
Suicide Risk Psychosis
Distorted
Perceptions
Aggression
GI problems
Just the Facts
ADHD Eating
Disorders
Omega-3’s and ADHD
A 2014 meta-analysis evaluated whether children
with ADHD have abnormal levels of blood lipids
compared to non-ADHD children
9 different studies, including over 500 participants,
revealed that children with ADHD consistently
and reliably displayed lower omega-3 blood
levels than their non-ADHD counterparts (on
average 38% lower)
Hawkey & Nigg. Clin Psychol Rev. 2014 Aug;34(6):496-505.
Six-month follow up of 200 children aged 8-16 randomized
to 300 mg DHA, 200 mg EPA, 400 mg alpha-linolenic acid,
+ 100 mg DPA or placebo
Omega-3’s and ADHD
Raine. J Child Psychol Psychiatry. 2015 May;56(5):509-20.
42% reduction in externalizing
behavior and 68% reduction in
internalizing behavior
Parents showed significant reductions in their own antisocial and aggressive behavior
Omega-3’s and ADHD
2016 review of 25 studies on omega-3
supplements for ADHD
The results overall showed evidence for successful
treatment of ADHD symptoms
“The dosage of stimulant medication could be
reduced when used in combination with
omega-3 PUFA supplements”
Königs & Kiliaan. Neuropsychiatr Dis Treat. 2016 Jul 26;12:1869-82.
Omega-3’s and Eating Disorders
Patients with EDs tend to present with low
levels of omega-3’s and highly imbalanced
omega-3:omega-6 ratios2
As many as half of all BED patients have a
history of depression
Women with AN are 57x more likely to commit
suicide than non-sufferers1
1. Keel. Arch Gen Psychiatry. 2003 Feb;60(2):179-83.
2. Swenne. Acta Paediatr. 2011 Dec;100(12):1610-5.
The Tragedy
Suicide is the SECOND leading cause of death for ages 10-
24.
Average of over 5,400 daily attempts by young people
grades 7-12.
One death from suicide every 40 seconds.
By 2020, the rate of death from
suicide will increase to one every
20 seconds.
EFA’s and Serotonin
EPA regulates serotonin function by controlling serotonin
release in presynaptic neurons
Patick & Ames. FASEB J. 2015 Jun;29(6):2207-22.
EPA promotes
serotonin release
Omega-3’s have been positively correlated with a serotonin metabolite in cerebral spinal fluid
DHA regulates the
serotonin receptor
Genetic Vulnerability
Children with ADHD were 60% more likely to have a single nucleotide polymorphism in the fatty acid desaturase 2 gene
Fewer omega-3’s are incorporated into the cell membrane
Low omega-3 concentrations in ADHD subjects with out lack in dietary intake
Brookes. Biol Psychiatry. 2006 Nov 15;60(10):1053-61.
It takes at least 10
weeks for cerebral
membranes’ highly
unsaturated fatty
acid levels to
recover following
chronic deficiency.
Not a Quick Fix
Bourre. Prostaglandins Leukot Essent Fatty Acids. 1993 Jan;48(1):5-15.
The Human Brain: The Franklin Institute
“By modifying natural fats, we have altered the
basic building blocks of the human brain -
weakening cerebral architecture. And, like
unstable buildings that come apart in an
earthquake or storm, poorly structured human
brains are failing to cope with the mounting stress
of modern life.”
Vyvanse (lisdexamfetamine) Review
2 controlled trials with 1,033 adults
↓ in weight ranged between 5.2% and
6.25%
Discontinuation rates due to adverse
events were low
Vyvanse 50 or 70 mg/d significantly ↓ #
of binge eating days per week
Citrome. Int J Clin Pract. 2015 Apr;69(4):410-21
Dasotraline
Dasotraline is under development for the
treatment of ADHD and BED
A novel dopamine and norepinephrine reuptake
inhibitor with slow absorption (10-12 hours) and
a long half-life (47-77 hours)
When rats were given dasotraline, they had significantly reduced impulsivity
Dasotraline for BED
Navia. 2017. APA Annual Meeting. Poster abstract P7-084.
Those taking
Dasotraline for BED
had decreased binge
eating days
Dasotraline for ADHD
Those taking dasotraline
8 mg/d had significantly
improved ADHD symptoms
compared to baseline and
compared to placebo
Koblan. Neuropsychopharmacology. 2015 Nov;40(12):2745-52.
Comorbidity of ADHD and Eating Disorders
Summary
Those with ADHD are more likely
to have an ED
Those with an ED are more likely
to have ADHD
These associations are
consistently found in samples of:
Males
Females
Children
Adults
Those seeking
treatment
and
the general
population
Prevention is Possible
Chart review of 252 patients, mean age 10
years, in two pediatric mental health clinics
Significant association between ADHD and
binge eating
26% of children with ADHD had binge-eating
behaviors vs. 2% of children without ADHD
Reinblatt. Int J Eat Disord. 2015 Jul;48(5):505-11.
Prevention is Possible
7,120 males and females from the Avon
Longitudinal Study of Parents and Children, a
cohort study of children in the UK
Childhood ADHD symptoms increased the risk of
binge eating later in adolescence
Sonneville. Psychol
Med.
2015;45(12):2511-
20.
Prevention is Possible
Regardless of BMI,
anxiety, or depression Yilmaz. J Adolesc Health. 2017 Aug;61(2):140-146.
Higher ADHD symptoms
throughout childhood and
adolescence were
associated with increased
disordered eating risk in
late adolescence
2,315 Swedish twins from a longitudinal cohort
ADHD checklist completed at ages 8, 13, and 16
Prevention is Possible
ADHD brain studies have revealed abnormalities in regions
that control motivation, satisfaction, and impulse control
Seymour. CNS Spectr. 2015 Aug;20(4):401-11.
These regions, particularly the hypothalamus, also regulate eating behaviors, and it is no coincidence that similar brain abnormalities tend to show up in cases of EDs
ADHD and Obesity
Genetic mutations that determine how many dopamine receptors are present and active may be one of the explanations for understanding the ADHD-ED connection
Genes provide the kindling
and environment provides
the fuel
Nutrition and Health
Understanding the
role of Nutrition
and Health is not
Alternative
Medicine
Psychiatry Redefined and Reimagined
Prevention is Possible.
Mental Illness may be seen as
a reflection of multiple errors in
physiology.
If we find the Causes,
we may find the Cures.
Thank You Psychiatry Redefined and Reimagined
Dr. Hallowell Dr. Shaw Dr. Lombard
James Greenblatt, MD Chief Medical Officer Walden Behavioral Care [email protected]
Thank you!
JamesGreenblattMD.com
Finallyfocusedbook.com