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Dr. Roberto Olivardia returns to the show to talk about ADHD and eating disorders in this bonus episode. He explains the different types of eating disorders — and why ADHD and eating disorders, like binge-eating disorder (BED), often co-occur.
Dr. Olivardia shares how ADHD symptoms like impulsivity play a role in eating disorders. He also talks about treatment options and what to do if you or someone you know is struggling with an eating disorder and needs support.
Find support at The National Eating Disorders Association.
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Laura: From the Understood Podcast Network, this is "ADHD Aha!," a podcast where people share the moment when it finally clicked that they or someone they know has ADHD. My name is Laura Key. I'm the editorial director here at Understood, and as someone who's had my own ADHD "aha" moment, I'll be your host.
I'm here today with Dr. Roberto Olivardia. Dr. Olivardia is a clinical psychologist who's based in Massachusetts. He's also an Understood expert and the host of Season 2 of the "Understood Explains" podcast, which is all about ADHD diagnosis in adults. If his voice sounds familiar to you, that's because he was a guest on a recent episode of our show, and we're so thrilled to have him here with us today to talk about ADHD and eating disorders. Welcome.
Dr. Roberto: Thank you for having me again.
Laura: My pleasure. It was so much fun to talk with you about your personal story and talk about something that will be probably difficult for some listeners to hear but is also important to share information about. Before we talk about ADHD and eating disorders, I want to get started by asking, if someone is struggling with an eating disorder or someone they know is struggling with an eating disorder, where do you recommend they turn to? What should they do?
Dr. Roberto: So, definitely to seek professional help because eating disorders are obviously, I mean, it's a psychiatric and psychological illness, but it's also a medical condition in that it affects your body in a lot of physical ways and a lot of mental ways. And it's the type of condition that can be very, very difficult for somebody to navigate without professional help.
And the sad statistics are that only about 10% of women who have eating disorders get help for them and get treatment for them. And for men, it's even far less. So, it is vastly undertreated. So, I recommend it could be starting to talk to your primary care physician for a referral. The National Eating Disorders Association is a phenomenal organization and they have treatment providers on their database, referrals that can be helpful, and just local experts in your community who specialize in eating disorders. Because it is a condition that you need to be working with someone who has experience and expertise in working with eating disorders.
Laura: Thank you so much. And we'll talk about treatment a little bit more as we go on. But I felt that that was important just to start with that. Don't cope alone. Get the support that you need. How about a basic definition of what is an eating disorder?
Dr. Roberto: So, in terms of the clinical diagnoses of eating disorders, there are three or four main ones. So, one is anorexia nervosa, which is characterized by severe restriction of caloric intake, which often results in weight loss and undernourishment, someone having less nutrition than their body really needs, and can result in a whole host of different adverse consequences in the body. It's often coupled with a distortion in body image for a number of people who might see themselves as looking larger than they actually are.
You have bulimia nervosa, which is characterized by binge eating episodes where somebody is consuming a large amount of calories than one would typically consume in a very short period of time, sometimes to the point of feeling sick or sometimes even passing out from eating too much. And then with bulimia, it's coupled with compensating behaviors like self-induced vomiting, laxative use, fasting, overexercise too, in an attempt to neutralize those calories, although it doesn't actually do that, and we can talk about that.
And then binge eating disorder, which is the binge episodes, but without those compensating behaviors.
And then there are other eating disorder conditions. One is avoidant, restrictive food intake disorder or ARFID, which refers to, it could be similar characteristics or symptoms of anorexia, but perhaps not have any body image component.
So, eating disorders don't always have to have a body image component of people having a distortion or having dissatisfaction with their weight. It could be a dysregulation of food and food intake. So, those are under the DSM of what you would see with disorders.
But then there's what we would call just disordered eating. And that could come in a whole host of different fashions of dysregulated eating, poor relationship with food, people who might eat healthily per se, but their self-talk around their eating can be very negative and very damaging. So, somebody who, let's say, is not particularly underweight or overweight, but every time they eat a cookie, they call themselves a pig. That's not good for the psyche. So, although medically there might not be an issue, but psychologically there's an issue in terms of how they're relating to food or their bodies in a lot of ways.
So, we see that sort of whole host. So, I think it's really important to because one of the reasons actually that people are not often likely to get treatment is they think, "Oh, an eating disorder is somebody who has to be 80 pounds or somebody who has to be 500 pounds or somebody who has to be vomiting after they eat." It can come in a whole host of different flavors.
At the end of the day, if you're somebody that has this very dysregulated, negative relationship with food, with eating, with body image, all of that can fit under the umbrella that warrants treatment.
Laura: Are people with ADHD more likely to have an eating disorder? And if so, why?
Dr. Roberto: I always start off by, it's so important to understand how ADHD affects every life domain. So, when we think about the core of ADHD in terms of executive functioning issues of impulsivity, that the things actually that we do every day are kind of the things that are most likely to be impacted by ADHD.
So, we did an episode previously about sleep and ADHD. People with ADHD often have issues with sleep. Eating is another one. There is a higher prevalence now, particularly for binge eating disorder and bulimia nervosa, and ARFID, that category of this sort of dysregulated relationship, less so with anorexia. We don't see a strong correlation of anorexia and ADHD. We often will find that the co-morbidity of anorexia is more likely in people with OCD, with obsessive-compulsive disorder.
Having said that, I have worked with patients with ADHD and anorexia. But primarily it would be more what we call the more impulsive eating disorders like bulimia, binge eating disorder, and or this ARFID category that might rely on people with ADHD who are either drawn to or defensive to certain tastes and textures.
So, why is it that people with ADHD? Well, studies show that we know with the ADHD brain that there's a dopamine deficit, basically, and dopamine being the neurochemical that's implicated in reward. And food can be a very stimulating, highly rewarding mechanism to an ADHD brain. And mind you, when people binge eat, when people impulsively eat, they're not doing it with kale and carrots. Most of the time, the foods that people with ADHD are drawn, and people with eating disorders, in general, are drawn to, are high sugar, high simple carb type foods. That is particularly rewarding for an ADHD brain. So, it's accessible, it's easy, it's legal.
So, all of these things that people with ADHD could use to reward, to soothe, to self-medicate, to distract themselves from other negative emotions, but also just impulsivity alone. There was a study done with kids with ADHD between the ages of 10 and 14 in a food lab. And they had a group of kids with ADHD, kids without, and they screen them beforehand on their level of hunger, preferences for food, and then basically just let them kind of be. And there was food available to them. And observed how much they ate, what they eat and all of that.
And afterwards, the study showed that, even after controlling for a bunch of variables, kids with ADHD ate more than the kids without ADHD. But what was interesting is that eating had nothing to do with their level of hunger, so, the pre-level of hunger had nothing to do with the volume of how much the kids with ADHD ate. Kids without ADHD, their level of hunger was correlated with how much they ate. But also the kids with ADHD even eat more of foods they didn't even really like. And when asked why they said it was there. It was just simply there.
And I sort of joke, but it's not a joke. I mean, with having ADHD myself, that we could be on a see-food diet where if we see it, we eat it. And so, sometimes it's as simple as that. Sometimes, I mean, the patients I work with, with ADHD, they don't hate their bodies. They might not have these deep, dark things that they're self-medicating. The issue is simply that the food is just there. It's just available to them.
Laura: Right. I remember when I interviewed you about your own personal story and you mentioned the Chuck E. Cheese incident when you were baffled as to how — was it your friend or relative? — was able to just say, "I’m not hungry anymore, I'm not going to have that other piece of pizza."
Dr. Roberto: Absolutely. Because to eat too, or eat healthily, it requires us to tune in and have what's called an interoceptive awareness, which we know people with eating disorders and people with ADHD have very low interoceptive awareness, which is tuning in to your hunger cues, your satiety cues. And I remember the very first time I went to a buffet, because I grew up in a house where my mom didn't believe in going out to eat because she's like, "I can cook it better." She goes, "They drop the steak on the floor and you don't know what they're doing with the meat." And she was a really great cook.
So, I remember the first time, I think I was in college, I went to one of those buffet places. And it was a perfect example of this because my intention was not to go and just binge on all this food. So, they had, like, I don't know, 120 selections of different foods. And the people I went with, you know, my friends, I remember my brother came with me, most people got maybe a little selection of, I don't know, 20 different kinds of food. I got a little selection of 120 foods.
Laura: Oh, wow.
Dr. Roberto: But the whole time, I didn't even think "I'm eating a lot," because I was eating just a little piece of this and a little piece of that and a little scoop of this and a little scoop of that, but of everything. Because my ADHD brain is like "Oh, let's try everything," you know, it's almost like it's a bargain. And at the end, I was so, I literally couldn't get out of the bench. I was like, "Guys, I can't move. Like, I literally feel like I'm going to get sick." And my friends were like, "Well, of course, like, you ate so much." They're like, "Where do you even put that?" And they couldn't even, I'm like, "But I wasn't stuffing my face or anything." And they said, "No, but you just..." they were amazed as to how much I could consume.
Now, if there were only 10 selections of the foods, I guarantee I would have been satisfied if I had a little piece of 10 things. It's not like I needed 120 things to be satisfied. But that's the thing with ADHD. We're so externally focused that those external cues inform the internal, as opposed to the other way around. Like, "Oh, I am satisfied. So therefore, externally I'm now going to stop eating." We have to train ourselves in a sense to do that.
And then when you think of all the psychological aspects of ADHD, the stress that can be involved in poor executive functioning, the negative ways that people with ADHD talk to themselves and their self-esteem, food can be just soothing for all of that.
Laura: So, binge eating disorder or BED, which is different than bulimia, which is something I only recently learned, that is the — correct me if I'm wrong — the only type of eating disorder that may have a genetic link to ADHD?
Dr. Roberto: Yeah, well, bulimia actually, because bulimia includes binge eating episodes typically, although some people with bulimia that I've worked with just purged, they don't binge. But because it has binge eating episodes that we know that there is that sort of overlap. And it's interesting because, in the '80s, I remember reading literature when I started doing, because I specialized in working with boys and men with eating disorders and have been doing that for 30 years, researching and writing and treating boys and men.
And I remember in the mid '90s they would refer to, there was this term called a multi-impulsive bulimic. And a multi-impulsive bulimic was an individual who had bulimia but also had a lot of other impulsive issues — substance abuse, shoplifting, kleptomania, which I guess would be the same as shoplifting, promiscuity — like all of these things that I remember as I learned more and more about ADHD, saying, "That's describing someone basically with ADHD." So, the interesting thing, though, about binge eating disorder is that the only right now FDA-approved medication for a binge eating disorder is Vyvanse, which is an ADHD stimulant medication.
Laura: Wow, I didn't know that.
Dr. Roberto: I remember years ago doing talks for both ADHD communities and eating disorder communities about the co-morbidity. And usually, I would have started the toss out by saying, like to an eating disorder group of clinicians, "How many of you treat individuals with ADHD?" And maybe some hands would raise and then I'd give the talk, describe ADHD, and then ask the same question and almost everyone would raise their hand and say, "Oh my gosh, this is exactly...." So the fact that Vyvanse is the medication for binge eating, clearly there's a linkage there.
Laura: It's interesting, my perception of eating disorders, especially even through pop culture, even when there's a little bit of armchair psychology in television or movies, you often hear people say eating disorders are about control, right? And it can seem counterintuitive because you seem like you're out of control. Can you talk more about that and maybe how that's related to ADHD as well?
Dr. Roberto: So, actually with anorexia, with bulimia, with binge eating disorder, a lot of times those behaviors can be fueled by dieting and dieting culture, which is very harmful in our culture. We really should never promote the idea that of a quote-unquote diet. And by a diet, meaning I'm not going to eat this thing because I want to lose weight, and then I lose the weight and then I can eat this thing. As opposed to "No, all foods should be on the table, but in moderation and regulation."
So, for a lot of people actually with, let's say, binge eating disorder, one of the biggest triggers sometimes can be somebody who has been dieting and trying to restrict their calories. And then your body just gets hungry, and it just is, we're done with this. And it tries to be, quote-unquote, in control, and then it becomes very out of control.
Other times, it could be somebody who is like, "Well, I can't," —especially people with ADHD — "I can't control the fact that I have trouble with time management. I can't control the fact that I blurt things out in class. But I can control what goes in or what doesn't go in my body. I can control what I do with my body after I have a binge, even if I can't control my food intake." And in the case of bulimia, "I could throw it up, I could use laxatives, I could do all this, and it will neutralize as if the event never happened." Which first of all, isn't accurate.
But the mechanism is there around this sort of sense of control. And it is a very out-of-control thing. And for people who struggle with eating disorders, it's a very tormenting process. It's a very, very difficult thing to treat. Recovery is 100 percent possible, but it's not easy because you really are kind of reorienting your relationship with food and trying to come up with other tools to deal with whatever might have triggered it in the first place.
Laura: And I can imagine how difficult that must be, in particular for someone with ADHD who, for example, maybe was constantly told when they were growing up that they were bad because they were struggling with behavior, right? And then this tendency, I imagine, to say, "Well, that's a bad food" or "I'm bad because I ate that cookie," that must make it so much more difficult.
Dr. Roberto: Oh, absolutely. I mean, so much of this is also just looking culturally from a larger landscape of how we think about and talk about food. This idea of, "Oh, I'm bad, you know, I had two cookies." Well, you know, "You're not bad. You had two cookies, period. That doesn't make you good or bad. It doesn't make you a better person or more worthy of love if you had salad today. You know, maybe you made a healthier choice. That's an accurate statement. "I made a healthier choice today."
So, even the vocabulary culturally of how we talk about food and bodies and then absolutely mentioning popular culture and the media. And I mean, we know that of women historically and boys and men, you know in my research showing from the early '80s on, are dictated by mass media and advertising of a certain body to be, which can impact everyone. But particularly for people with ADHD, where it's so easy to feel like you don't measure up on so many other ways that I've seen sort of this higher prevalence of adhering, "Well, if I can't measure up by being the smartest person or the most productive, I could have the best body."
And so, people with ADHD are more susceptible to those kinds of messages of if you look like this, you're going to gain more acceptance, you're going to gain more accolades. People are going to be like, "Wow, you're disciplined," because we associate like diet behavior with discipline and willpower and words that people with ADHD have heard about other things. You know, "If you had the right discipline, you'll get that schoolwork done and you have the right willpower you'll just stop eating or drinking," or whatnot.
And it's not about those things. It's about recognizing the wiring that we have and how we just have to work at it a little bit differently. But it's tough nowadays with social media the studies are profoundly showing these significant correlations of social media use and body dissatisfaction in young people.
Laura: In your experience, when patients come to you say, for because of an eating disorder, do they usually discover that they have ADHD after they've discovered that they have an eating disorder? Like what has been that trajectory? Or is it the other way around usually with you, or are they aware of both? What's that like?
Dr. Roberto: So, usually one of two things are the most common. One is people who may know they have ADHD, and they know they have an eating disorder, but never connected the two, or thought there was a relationship between them. And that is why I love that we're having this discussion, because people will hear this, and when I get emails from people around the world that say, "Oh my gosh, I know — my provider never mentioned this. I never understood why I couldn't even get a handle on the treatment of...." Even people who are in treatment for an eating disorder but where the, if the ADHD piece is missed or if it's not understood through that lens, it's just, it's not going to gel in the same way.
Or the second scenario is, and this is particularly true for adults who I see for an eating disorder, and then it turns out that they have ADHD. And they're like, "Oh my gosh, you know, this makes sense." And this is a common scenario where I'll do consultations or meet with someone who, let's say, has an eating disorder, but then has a history of alcoholism and a history of gambling addiction and a history of sexual addiction. And it's just like the eating and the binge eating is almost just the next step, the next addiction, in a sense.
And when we understand it through that lens, people often feel just validated because for them before that, they're like, "I literally am so weak-willed that I have this problem and that problem and that addiction and that," and when they realize, "Oh, wait, this is all coming from the same place," if we sort of the root of this kind of ADHD wiring and therefore the benefit of once we identify it, now we can treat it.
And this is where with ADHD and eating disorders in particular, like stimulant medication, which has been very contraindicated in the eating disorder community for years because it's been, you'll sometimes see individuals who abuse it because it can have an appetite suppression effect. But studies show for patients with ADHD and bulimia, and of course, now we know with binge eating disorder, seeing that Vyvanse is FDA approved, studies show that stimulant treatment actually results in better treatment overall and less relapse of their eating disorder.
Laura: So, you specialize in eating disorders and ADHD, and in particular, you specialize in eating disorders in men and boys.
Dr. Roberto: Yes.
Laura: Is there any sort of unique connection to ADHD there that you can speak to?
Dr. Roberto: I guess a lot of the same things. I mean, I see definitely the prevalence of ADHD in a lot of the boys and men that I work with, and sort of impulse control issues, and self-esteem, body image, the need to fit in, you know, it's almost like the themes that you would see with lots of people with body image issues and eating disorders. It's just a little bit, it's more heightened, you know, for people with ADHD, because they often don't feel like they fit in or don't fit in because of their neurodiverse condition.
So, that's something that luckily, I mean, I've been seeing just more awareness and people who are getting — males that I treat who are getting treatment earlier and it's being identified more. But when I started, I remember the first study I did, it was literally 30 years ago, and it was college students who had not been in treatment for eating disorders, and I did it as a thesis in college. And my thesis committee said, "This is a great idea, but you might need a plan B because you might not have a lot of guys responding and you don't know how many guys are out there that are willing to talk to you about this."
So, I put an ad in — I'm in the Boston area, we have a million colleges around here — and I remember coming home on the day that the ads were released, and my answering machine tape was full of messages from guys saying, "I can't believe someone's studying this. I thought I was the only one. I... sign me up. I want to just talk to somebody." And these men had, some of them had very, very serious eating disorders, I mean, like life-threatening parts of where they were in their life. And then, of course, I gave them treatment referrals. But they're out there.
You know, and in 2000, I co-wrote a book called "The Adonis Complex," which talks about all different kinds of eating disorders, body image issues that affect boys and men. And I remember when that came out and then there was just more awareness that now we see that more. And it's not, I mean, it's still when I tell people that that's something I specialize in, they're like, "Really? The boys, that many boys and men?" But that's less so than what would happen, you know, years ago. But I definitely see the ADHD as well as just with learning differences as well, that sense of, you know, if I feel I failed in this area, then I'm going to fuel everything and to try to succeed and getting the best body.
Laura: Is there anything else you want to share about treatment and coping with eating disorders with or without ADHD?
Dr. Roberto: Just that, you know, recovery is possible is probably the first most important thing that I want people to know. And it does require work, and most often an interdisciplinary team of a therapist, a nutritionist, family support. And it's something that can be hard. And to know, though, that once — when people are free of that kind of very negative relationship, you can still enjoy food and you can enjoy all of those things. It's just sort of in a more regulated fashion.
And with ADHD in particular, is to know when people can work through that, it does generalize to other things that, you know, when you sort of learn those skills of regulation of one area of your life, it does help with learning those kind of skills of regulation in other areas. But when ADHD is present is like anything else, you always have to be treating the ADHD with the eating disorder. It can't be, "Oh, we'll treat that after," because untreated ADHD will undermine the treatment of an eating disorder. So, you always have to be treating it alongside.
Laura: One last question. If anyone listening doesn't have say, insurance, or they can't access the kind of care that you were just talking about, is there any place where they can turn to where they could have access to the kinds of services and support that they need for eating disorders?
Dr. Roberto: Yeah, I mean, I think just in general, you know, if they have any kind of primary care physician community, you know, mental health clinics, again, I would direct people to the National Eating Disorders Association where there are resources. And for people even there's some online support groups that are free, that some of them are led by professionals in terms of just even getting basic support. Because that's a huge part of it, too, is just having a sense of community and support in your treatment to know that you're not alone and that the judgments that you might even have for yourself when you're part of a group of people who can affirm that this isn't an issue of you being a bad person or a weak person, that can sort of open somebody up to help them.
And with any support group, you know, obviously, you have to kind of vet it out a little bit, especially if it's not professionally led. But I've had patients over the years who are in support groups that they find a lot of comfort and solace and support in.
Laura: Dr. Roberto Olivardia, thank you so much for joining me today to talk about this very important topic.
Dr. Roberto: My pleasure.
Laura: And everyone check out "Understood Explains" Season 2. You can hear a lot more from Dr. Olivardia there.
You've been listening to "ADHD Aha!" from the Understood Podcast Network. If you want to share your own "aha" moment, email us at ADHDAha@understood.org, I'd love to hear from you.
If you want to learn more about the topics we covered today, check out the show notes for this episode. We include more resources as well as links to anything we mentioned in the episode. Understood is a nonprofit organization dedicated to helping people who learn and think differently discover their potential and thrive. We have no affiliation with pharmaceutical companies. Learn more at Understood.org/mission.
"ADHD Aha!" is produced by Jessamine Molli. Say hi, Jessamine!
Jessamine: Hi everyone.
Laura: Briana Berry is our production director. Our theme music was written by Justin D. Wright, who also mixes the show. For the Understood Podcast Network, Scott Cocchiere is our creative director, Seth Melnick is our executive producer, and I'm your host, Laura Key. Thanks so much for listening.
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