Distracted and Hungry: The Relationship Between Attention Deficit Hyperactivity Disorder (ADHD) and Eating Disorders

Transcription

1 Distracted and Hungry: The Relationship Between Attention Deficit Hyperactivity Disorder (ADHD) and Eating Disorders Roberto Olivardia, Ph.D. Harvard Medical School

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3 What is Attention Deficit Hyperactivity Disorder (ADHD)? I. Inattention Poor attention span on boring stimuli Hyperfocus on interesting stimuli Drawn to thrill seeking/stimulating activities Distracted very easily Hard to follow directions Forgetfulness Incomplete projects or activities Procrastination

4 What is ADHD? II.Impulsivity Hyperverbal Very emotional/low frustration tolerance Decisions Impatient Impulse Control Habits Interrupts

5 What is ADHD? III. Hyperactivity On the go, Always in motion Hard time sitting through long classes/sessions Restlessness, Constantly fidgeting Mentally racing, Multiple thoughts at once

6 Executive Functions Our ability to manage, coordinate, plan and anticipate, like the conductor of an orchestra: Our Brain s CEO. I. Attention management Sustain focus Shift attention Manage Hyperfocus Transition from one thing to another Trouble shifting attention can result in inflexibility and look oppositional II. Action management Control, self-monitor and learn from mistakes. Difficulties can lead to frustrating, unintentional misbehavior. Learn more slowly from behavioral interventions than others or to be careless in their work.

7 Executive Functions III. Task management Organize Plan Prioritize Manage time Attempts to manage ADHD can be undermined by ADHD IV. Information management Remember, organize and retrieve information

8 Executive Functions V. Emotional management Experience emotions without impulsively acting on them The Failure to Suppress Emotions Anterior Cingulate Cortex Regulatory systems for behavior, attention and emotions fmri shows lower activity in ADHD Supposed to help soothe/regulate/inhibit amygdala Amygdala gone wild, Emotionally impulsive Normal emotions but without boundaries

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10 Executive Functions VI. Effort management Persevere when activities are challenging (stick-to-it-tiveness) Work efficiently Often gets labeled as poor motivation ADHD is not related to intelligence Not about knowing what to do About Doing what you know Actualizing your intentions

11 ADHD Facts 4-8% of prevalence (most likely higher) Affects all genders, races, ethnic backgrounds, socioeconomic levels Manifests in different ways for different people in different developmental stages Can you outgrow ADHD? ADHD Spectrum rather than categorical 50%-60% have a learning disability

12 The ADHD Brain An under aroused brain (low dopamine) An uninhibited brain (low GABA) Motor coordination differences (cerebellum differences) Frontal lobe takes longer to mature Frontal lobe size differences 30% less chronological age in executive functions GENETICS: The apple does not fall far from the tree. DRD4 Gene (Risk taking, reward seeking)

13 Is ADHD an illness? Does not suggest brain damage or defects ADHD is not a mental illness Simply a way the brain is wired Context specific Kenyan tribe: Nomads with DRD4 gene better nourished and healthier than their non-nomadic counterparts Goal is to create the optimal environment for the ADHD brain Not every strategy works for every ADHD person every time, even within an individual Effortful at first to figure out but worth it over time ADHD affects virtually every life domain

14 ADHD and Comorbid Disorders ADHD rarely travels alone Spotlight typically on comorbid disorder ADHD is often undiagnosed Even when diagnosed, impact underestimated

15 Hartman et al (2012): ADHD and Impulsive Eating Lab Experiment to assess mood, impulsivity and loss of control eating in year olds. Mood was reported pre and post eating Liking of food reported Results: ADHD group ate more. NOT influenced by negative mood, level of hunger or liking of food

16 Altfas (2002) ADHD and Obesity Bariatric patients (N= 215) Found 27% had ADD (all inattentive type) For BMI >40: 43% had ADD Mean weight loss: ADD/OBESE patients = 2.6 BMI NON-ADD/OBESE = 4.0 BMI (p<.002) Mean weight loss For BMI>40: ADD/OBESE= 2.9 BMI NON-ADD/OBESE = 7.0 BMI (p<.004) ADD patients had more treatment visits with longer duration

17 ADHD and Eating Disorders Biederman et al (2007) ADHD girls are 3.6 times more likely to have an eating disorder (bulimia nervosa and BED) University of Virginia and Univ. Of California (2008) o Bulimia more common in ADHD adolescent girls than non-adhd adolescent girls. o Impulsivity main risk factor. Surman et al (2006): 11% of ADHD women vs 1% of non-adhd reported bulimia.

18 Bleck, DeBate, Olivardia (2015)

19 Studies of ADHD and Eating Disorders Svedlund et al (2017): 31% of 1165 E.D. patients above ADHD screening cut-off Nazar et al (2016) Meta-analysis: ADHD three-fold risk of eating disorders Mattos (2004): 10% of ADHD sample had E.D. (primarily BED) No current studies that focus on Anorexia Nervosa and ADHD

20 How can ADHD predispose someone to develop an eating disorder?

21 Poor organization skills Poor meal planners Cognitive Factors Difficult to think in not now ways Cooking without all ingredients Not considering time for thawing/defrosting Less likely to have supermarket list and tend to buy impulsively Leads to over reliance on fast foods and junk food

22 Cognitive Factors Decision-making can be difficult, or impulsive. Procrastin-eating Cognitively overwhelmed by all the contradictory information about food and diet. Impairs ability to make good decisions. Food can be means of gaining executive fuel ADHD individuals can be obsessive-compulsive and all or nothing in thinking

23 Regulation Factors Poor self observers/self regulators * Underestimate the amount of calories eaten Poor interoceptive awareness (same as in ED) Ignore physical cues of satiety or hunger Poor sleep habits Skipped meals leading to overeat on carbs, fats, sugars

24 Regulation Factors Sense of time is non-linear (now/not now) High-stimulating jobs where eating is inconsistent or en route. In hyperfocus can go hours without eating, then hit with wall of hunger More likely to eat while doing other things leading to poor regulation of food intake (snacking and grazing throughout the day) Restriction can be overcompensation for normative impulsivity

25 Emotional Factors Boredom leads to eating as a form of self-stimulation. (Can mimic depression) It s either a cigarette, my nails, or food. Anger, sadness, stress relief Food as reward, pleasure (not necessarily as a result of dysphoria) Relief from racing thoughts and distraction Sensual aspects of food are incredibly grounding ADD very outcome driven, instant gratification, impatient, needs results quick, impulsive

26 Emotional Factors Attracted to crash diets, quick fixes ADD likely to use caffeine as self-medicating which predisposes for later binge. Caffeine often in form of sodas and coffee with sugar and creams Plateau phase of weight loss or exercise plan very frustrating Food preoccupation incredibly reinforcing as a grounding mechanism Purging/Excessive Exercise: Euphoric stimulation

27 Self Esteem, Control and Shame Individuals with ADHD often struggle with self esteem issues due to failures, impulsive acts, and unrealized intentions Food becomes a way to cope. Easily accessible, comforting Best friend/worst enemy I can eat because I ve been good today. Food deprivation is an ultimate form of self-punishment

28 Self Esteem, Control and Shame Focus on weight can be extremely satisfying and concrete for self esteem Eating disorders are often about control, which many with ADHD feel they lack. If I control my weight, I control my life. ADHD need constant feedback from their environment. A number on a scale and body checking provides that.

29 Biological/Genetic Factors Reward deficiency syndrome : Insufficient dopamine-mediated natural reward produce need for unnatural rewards (food, drugs) ADHD brain craving dopamine and lacks proper brakes ADHD brains respond more intensely to dopamine spikes Binge eating/purging also common after other dopaminerelated activity (sex, fun event etc) as way of medicating dopamine drop and keeping the dopamine flowing Dopamine receptors could overlap with both obesity/binge eating (DRD2, DRD4) and ADD (DRD4) DRD4: novelty seeking

30 Biological/Genetic Factors Zametkin et al (1993) ADHD brain slower to absorb glucose than non-adhd Lowest in prefrontal brain Executive controls are demanding energy by any means necessary Leads to higher sugar and simple carb consumption (Kale doesn t cut it!) Serotonin in carbs, sugars, boost well-being. ADHD avoidant of negative affect Adrenaline shuts down digestion and diverts energy. ADHD more attracted to adrenaline events on constant basis, leads to a dysregulation of digestion

31 Treatment Address ADHD and ED together Destigmatize ADHD Destigmatize the eating disorder or weight issue * Especially needed for men Therapist must be a creative coach

32 Behavioral Strategies Behavioral scheduling/structure (especially nights) Generate list of alternative stimulating behaviors. THINK ADHD! Sleep hygiene Preventing Yo-Yo dieting caused by unhealthy weight loss methods

33 Psychopharmacological Approaches Stimulant meds (Ritalin, Adderall, Concerta) increase selfmonitoring, consistency, organization, and focus by increasing dopamine Drimmer (2003) Before Adderall: binging and purging 3-5 times daily After Adderall: only once every 9-10 days Dukarm (2005) Was bulimic for 3 years when diagnosed with ADHD After 2 weeks on stimulants symptoms completely remitted. Even after 15 months, no sign of bulimic symptoms

34 Psychopharmacological Approaches Schweickert (1997) 25 year old female diagnosed with ADHD at age 7 and BN at 13 Complete cessation of eating binges after methylphenidate due to improved concentration, decreased restlessness, and less impulsivity Complete remission of binge eating symptoms, at 16 week follow up, with weight remaining stable Keshen et al (2013) Stimulants in ADHD/BN group significantly reduced bulimic symptoms In addition, their weight remained in a healthy weight range, despite appetite suppression

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36 Distracted and Hungry: The Relationship Between Attention Deficit Hyperactivity Disorder (ADHD) and Eating Disorders Roberto Olivardia, Ph.D. Harvard Medical School