ADHD & Eating Disorders with Dr. Jean Doak
This week, Nikki and Pete dive into the complex and often overlooked relationship between Attention Deficit Hyperactivity Disorder (ADHD) and eating disorders. Joined by special guest Dr. Jean Doak, a professor of psychiatry and clinical director at the Center for Excellence for Eating Disorders at the University of North Carolina at Chapel Hill, the trio explores how these two conditions can intertwine and exacerbate each other.
Dr. Doak sheds light on the broad spectrum of eating disorders, extending far beyond the commonly known anorexia nervosa and bulimia nervosa. She emphasizes that eating disorders can manifest in various ways, affecting people of all genders and ages. The discussion delves into the biopsychosocial model, which considers biological, psychological, and social factors contributing to the development of both ADHD and eating disorders.
Dr. Doak explores the similarities between ADHD and eating disorders, such as perfectionism, poor impulse control, and difficulties with delayed gratification. They stress the importance of comprehensive screening for co-occurring mental health disorders to provide early intervention and treatment.
This episode sheds light on a topic that is often misunderstood. It serves as a reminder for clinicians, individuals with ADHD, and their loved ones to be aware of the potential comorbidity between ADHD and eating disorders. By fostering open discussions and increasing awareness, we can work towards better recognition, support, and treatment for those affected by these challenging conditions.
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Pete Wright:
Hello, everybody, and welcome to Taking Control: The ADHD Podcast on TruStory FM. I'm Pete Wright, and I'm here with Nikki Kinzer.
Nikki Kinzer:
Hello, everyone. Hello, Pete.
Pete Wright:
How are you doing?
Nikki Kinzer:
I'm doing good. How are you?
Pete Wright:
Well, I'm better. Can you believe last time we recorded just a week ago, I said I'm feeling a little sick, and in that time since we recorded, I got COVID and recovered? What do you think about that? I'm getting good at it.
Nikki Kinzer:
You're getting better at it because the first time you had it, that was not the same story.
Pete Wright:
No.
Nikki Kinzer:
No.
Pete Wright:
Well, that was a month and a year of recovery. The second time was about a week and a half, and now I'm on like four days.
Nikki Kinzer:
A week, yeah.
Pete Wright:
That's pretty good, pretty good.
Nikki Kinzer:
Not bad. Not bad.
Pete Wright:
It's nice to be up and in the circle.
Nikki Kinzer:
Glad you're feeling better.
Pete Wright:
[inaudible 00:00:57]. Oh, my gosh. We have such a great show today. This is a topic, we've talked about this topic before. It is very, very close to you. We're talking about eating disorders and ADHD, and we have a fantastic guest on the show with some incredible experience to share, and so I'm excited to get to that.
But before we do, you know the drill, you got to head over to takecontroladhd.com and get to know us a little bit better, and listen to the show right there on the website, or subscribe to the mailing list right there on the homepage and we'll send you an email each time a new episode is released. You can connect with us on Facebook or Instagram or Pinterest. Pinterest is blowing up y'all. Did you know Pinterest was still a concern?
Nikki Kinzer:
And it's like it has the highest social-
Pete Wright:
Yeah, referral links.
Nikki Kinzer:
Yeah, referrals for us.
Pete Wright:
The highest of all the platforms...
Nikki Kinzer:
Like really high.
Pete Wright:
... by a factor of 10 come from Pinterest. Mind blown.
Nikki Kinzer:
Who knew? Who knew?
Pete Wright:
Who knew? That's exactly right. So Pinterest at Take Control ADHD. But to really connect with us, join us over on our ADHD Discord community. Super easy to jump into the general community chat channel. Just visit takecontroladhd.com/discord and you'll be whisked over to a general invitation or log in if you're already a Discord user. If you're looking for a little more, particularly if the show has ever touched you or helped you understand your relationship with ADHD in a new way, we invite you to support the show directly through Patreon. Patreon is listener supported podcasting. With a few dollars a month, you can help guarantee that we continue to grow the show, add new features, and invest more heavily in our community. Visit patreon.com/theadhdpodcast to learn more.
Dr. Jean Doak is a professor of psychiatry and clinical director in the Center for Excellence for Eating Disorders at the University of North Carolina at Chapel Hill. Today, she brings her extensive experience in the field to talk to us about the relationship ADHD can have with eating disorders. Jean, welcome to the ADHD Podcast.
Dr. Jean Doak:
Well, thanks Nikki and Pete, glad to be here. And I would've never guessed that Pinterest would've been your primary source of referrals.
Nikki Kinzer:
I know.
Dr. Jean Doak:
I don't understand that algorithm at all.
Pete Wright:
I don't either.
Nikki Kinzer:
We don't either. Yeah.
Pete Wright:
Bonkers, that was just bonkers.
Nikki Kinzer:
Went crazy.
Dr. Jean Doak:
Yeah.
Nikki Kinzer:
Yeah, yeah.
Pete Wright:
Anyway, thank you for being here. We're talking about eating disorders, and we've talked... I think, Nikki, correct me if I'm wrong, we talked about a fair spectrum of eating related topics on the show.
Nikki Kinzer:
Right, yes.
Pete Wright:
And from maladaptive relationship with food to eating disorder seems to be the spectrum. And I wonder if you could start us off, Jean, with just help us get our frame of reference. What is an eating disorder versus somebody who just has a complicated relationship with food?
Dr. Jean Doak:
That's a great question, and I'm really glad you mentioned this idea or notion of a spectrum because there truly is a spectrum. There could be disordered eating all the way through toward a diagnosable eating disorder. And when we mention eating disorders, it's a very broad category of several specific eating disorders.
So if I were to kind of broadly describe what constitutes an eating disorder versus something that's disordered eating or unhealthy eating, it would be engaging in a pattern of behaviors where there is either a restriction of nutritional intake or a binging of nutritional intake that may or may not lead to weight fluctuations.
What we do know is that with some eating disorders, there's associated features of weight gain. With other eating disorders, there is an eating pattern where one is eating in an uncontrolled way or fashion with some shame and guilt associated with that. With many eating disorders, there are some significant and acute medical consequences where someone may need some immediate medical attention as well. So that's the broad definition of what would constitute an eating disorder.
Pete Wright:
Well, that's really broad, but how do you know when it's something that needs to be treated?
Dr. Jean Doak:
Great question. And so in a similar way, when we think about other mental health diagnoses, we think about to what degree does it interfere with day-to-day functioning? That is kind of the first swath that we look at. So to what degree does it interfere with an ability to eat throughout the day, to eat outside of the home, to eat at school, to eat at someone else's house, to eat with a wide variety of foods, to not eat in a way that's restrictive, to have a very broad range of caloric intake, a broad range of food items, to not eat in secrecy, to not eat with shame or guilt? That would be like eating patterns.
When we think about other eating disorder behaviors that are maladaptive, we think about behaviors that people engage in to rid themselves of food or holding onto the calories. Sometimes that would be misuse of diet pills, misuse of laxatives, purging behaviors and/or even hyper or over exercising, over exercising to the point where there's inflexibility, there are harmful effects or impact on the body. Those would be indicators that one might want to seek out assistance.
Pete Wright:
Yeah, see, my experience with eating disorders is what I learned on after school specials when I was a kid. It was either anorexia or bulimia. And you've just described a whole bunch of stuff that is then not mentioned either of those terms. So you've now broadened my horizons well beyond after school specials.
Dr. Jean Doak:
Well, and I want to validate that. I will say, I'm going to guess maybe we're around the same age, but it wasn't through the '70s, '80s, and even early '90s, there were really three broad categories of eating disorders. There's just a lack of understanding of how eating disorders can manifest with different genders, different populations, different ages, et cetera. So you are correct. It used to just be anorexia nervosa, bulimia nervosa, and then a catchall category that was called eating disorder not otherwise specified...
Pete Wright:
[inaudible 00:07:53].
Dr. Jean Doak:
... which meant that it just didn't meet the criteria for-
Nikki Kinzer:
Could be anything.
Dr. Jean Doak:
Yes, exactly. And so as there've been more clinical trials and more research done in the latest iteration of the DSM-5, which is the Diagnostic Statistical Manual for mental health disorders. There are one, two... There are more than five, I think, eating disorders. And even then, there still is one category of an eating disorder that is kind of sub-threshold, but nonetheless, we have a better understanding of all sorts of different eating disorders and how they present across the population.
Nikki Kinzer:
Well, and something that you said earlier when you were defining it is, is it something that's impacting their daily life? What is that impact? And our listeners that have listened to this show for a while or just are listening know that my daughter has suffered from an eating disorder. And so I've seen these different stages in her life. And one of the things that I think is so impactful in their daily life is that it just consumes their thinking. And so that's all that their thinking is, how many calories can I get away with not having today? And it's also a lot of secrecy. I didn't know that she was suffering for months. So I'm curious to know from your standpoint too, from the patients or the person that's suffering, it's so secretive, I think, at first. You don't notice it. Is that fair to say or...?
Dr. Jean Doak:
It's very fair to say, and it's very common. We often say that eating disorders thrive in secrecy and really take advantage of isolation. And so as you can imagine early on in COVID, the rates of referrals for eating disorders skyrocketed, not because there is just all of a sudden an increased prevalence, but because we were also isolated. And so it provided this kind of perfect storm of an opportunity for eating disorders to exacerbate.
But yes, there's a great deal of secrecy, a great deal of shame. I think some of that is also associated with the stigma related to eating disorders. It's not too unlike other mental health disorders as well, there's stigma and shame associated with many mental health disorders. But in particular with eating disorders, I think the general stereotypical perspective still holds true for many people that the general population probably believes that an individual brought on the eating disorder themselves, or an individual with an eating disorder is self-centered and they're just doing it for appearances or appearance purposes, or it's just a diet that got out of control. So there are a lot of false kind of stereotypical understandings that can perpetuate that shame and guilt.
Nikki Kinzer:
Well, and what I got from my friends and family was, "Oh, she's just being a typical teenage girl who cares about what she looks like or is caring about what other people think of her. So she's just going through what everybody's going through," and I'm thinking, no, it's different. There's something here that's very, very different that I didn't know at first what it was until we explored it more. But yeah, I think that the stereotypes are still there. And what about boys, because that I can imagine gets really underdiagnosed?
Dr. Jean Doak:
It's a great question. It absolutely is underdiagnosed and often is a missed diagnosis. And so even when we think about prevalence rates, the prevalence rates we have are even skewed because we still know that males get diagnosed less so because males are screened less so. And it's because males are often thought to not necessarily struggle with an eating disorder. And so you are correct. What we do know with eating disorders is that any gender can be affected by an eating disorder. And in fact, any individual at any age can be affected by an eating disorder. So not just children and adolescents, but adults as well.
Pete Wright:
Like later onset eating disorders?
Dr. Jean Doak:
It could be later onset eating disorders. It could be an older individual who struggled with an eating disorder throughout their lives and maybe never were diagnosed, were never identified, never screened, never diagnosed. So it could be both. And we do know that there are certain life stressors that can create that opportunity for an eating disorder to come on board as well.
Nikki Kinzer:
Well, because this is not about vanity.
Dr. Jean Doak:
Correct.
Nikki Kinzer:
And I think that that's really important to understand. So when we were in therapy and we were talking, we had a family therapist that would help us through some of this. And I remember her saying to us as parents, "Remember that this is a disease. Remember that when she's mad at you and she's lashing out, that is not her. That is the eating disorder." And it took me a while to understand that this was not about vanity, this was not about how she looked, it was all about, for her, having some kind of control when she felt so out of control, and she has ADHD, she has depression, she has anxiety, and now she has this.
So there's so many things that are out of control. So it took me a while to understand, "Well, that's how she's coping because this is the one thing that she really does have some control over." Now, that's just her situation. You see patients and you talk about this all the time. So I'm just curious, what other underlying things contribute to a possible eating disorder?
Dr. Jean Doak:
That's a great question. I do want to just give a shout-out to your therapist. What a fantastic thing for your therapist to share with you. I think that is a wonderful opportunity to really talk about how the eating disorder disease process almost acts like a veil over the individual. And so we work really hard to tease out the individual from the eating disorder.
And what I mean by that is that at some point in an individual's life, they existed without the eating disorder. And so we know that they too can exist after the eating disorder, and that the eating disorder just takes over in a way, takes over thoughts, takes over behaviors, takes over feelings, takes over how their body, from a physiological perspective, operates. And so it is a very concerted effort to tease those two things out, the individual from the eating disorder.
But going back to your question, one of the things that we do know also about eating disorders, although there's not one thing that contributes to an individual developing an eating disorder, we do know that it could be multiple factors. And there is this model called the biopsychosocial model that contributes to the development of an eating disorder. And interestingly, it's a similar model when we think about ADHD as well.
So I'm going to break it down. There's the bio piece, there's the psychological piece, like personality traits, and then the social piece. The biology is the genetics. So we do know that for many mental health diagnoses, there's a genetic factor that contributes to the development of various disorders. Obviously, there would be a higher degree for a first degree relative with ADHD or an eating disorder. There's a greater likelihood that somebody might have ADHD or an eating disorder. It's not always the case. It's not always a direct one-to-one correlation, but that's the highest rate of that. Other mental health disorders can contribute to any other mental health disorders just at varying rates. So that's the biology or the genetic piece.
Then the psychology piece or the personality piece, there are personality traits that may contribute to it as well. So oftentimes with... I'm going to bring up anorexia nervosa. One of the hallmark personality traits that we often see is perfectionistic traits. And so that is something that we see quite often. For some other eating disorders, what we can see are some impulse regulation difficulties or challenges, which interestingly, when we think about ADHD and kind of personality traits, there's an overlap there as well.
And then the social piece for eating disorders, we think about our society and our culture and what people are exposed to, whether it be the diet culture or the promotion of a thin ideal or certain types of body sizes or shapes. And so we think about the biopsychosocial model, those three broad areas contribute together, swirl around together, and that's what we do know contributes to the development of an eating disorder.
Pete Wright:
So since this is ostensibly a series that we're doing, we've been talking about all these comorbidities. We've talked about anxiety and depression and OCD and ADHD over the last several weeks, and everything you just described, particularly in the psycho of the biopsychosocial model, talking about self-image and the struggles with... They just seem very familiar to me living with ADHD. Like it seems like there's a Venn diagram somewhere that's approaching a circle, and it's curious to me how those behaviors in one person might manifest as OCD or anxiety, where in some it can manifest, to Nikki's point earlier, like taking control back in an area where ADHD has made me feel completely out of control. Am I talking about it in a way that sort of makes sense or am I just making stuff up at this point?
Dr. Jean Doak:
No, it absolutely makes sense. And this is where we may have a genetic pathway that may lead us in one direction. And what I'll say related to your question is that we know from sibling studies, for example, or twin studies, and they've been done with ADHD and they've been done with eating disorders. Just because there's a genetic propensity or just because siblings live in the same environment doesn't mean that every child in the home will develop ADHD or develop an eating disorder. They can manifest in different ways.
Some of that is related to the personality or the psychological component because not every child in a family is exactly the same. Even identical twins aren't exactly the same, they're genetically the same, but from a personality perspective, could be very different. Even how individuals grow up and develop their sense of self, self-worth, those kinds of things are different. So again, it's kind of the soup, everything that goes into the soup that creates those differences.
Pete Wright:
So speaking then of the ADHD relationship, specifically with eating disorders, I don't want to minimize the relationship, but can you start us off talking about how ADHD can exacerbate or impact eating disorders, or I guess the other way around? I'm looking to figure that out. One of the interesting things we've been talking about over the last couple of weeks is this idea of you can't really address one thing without knowing fully about the other. They get in the way of each other and can sort of mystify you as a clinician. How does that work with these two conditions?
Dr. Jean Doak:
Yeah, I think ideally what would... This is just my ideal world. I would love for every clinician to screen for every mental health disorder. I would love that for everybody, and everybody has a fair shot to have an early diagnosis, which can lead to early intervention and early treatment and early recovery. That would be wonderful. In the absence of that, one of the things that we try to do a better job at is educating clinicians about potential risk factors and the interplay with high co-occurring disorders. So you mentioned depression and anxiety high co-occurring with ADHD. Interestingly, high co-occurring with eating disorders as well.
And so I think when we think about similarities, we think about similarities in features. So I mentioned earlier when I was talking about the biopsychosocial model, some of those personality constructs or traits, so that issue of perfectionism, to what degree does that play into ADHD or any issues related to performance? That's one of the things that we would want to have a little flair to go up in our brain like, "Oh, okay, this is a associative feature. What other associated features might this be linked with?"
Another thing I mentioned as well is poor impulse control. And so again, as a clinician, when I hear poor impulse control or if I'm asking questions related to that, I'm thinking, "Okay, I need to be thinking about ADHD. I need to be thinking about maybe less so OCD, but other things as well." When I'm thinking about perfectionism, I might be thinking of an eating disorder and OCD.
Another thing that we also ask about would be delay in gratification. To what degree can somebody engage in that, or to what degree is that part of their personality? Again, that might provide other flares that go off in my brain about other co-occurring diagnoses.
Disorganization, disinterest. Interestingly, with disinterest and a little bit of disorganization, there are some personality traits affiliated with one particular eating disorder. It's called ARFID, that also can overlap with ADHD, that can also overlap with autism.
Nikki Kinzer:
Oh, interesting.
Pete Wright:
Wow.
Dr. Jean Doak:
We think about these things not just, "Okay, I need to think about this disorder and the categories." Instead, I would like to promote, "Okay, I'm thinking about these personality traits and in what way do these personality traits that I'm seeing lead to various disorders?" And I think that would be a better way for us to do a better job at screening not just for one type of mental health diagnosis, but other co-occurring diagnoses.
Nikki Kinzer:
What is ARFID?
Dr. Jean Doak:
ARFID is an acronym that stands for avoidant food intake eating disorder. And so it's a newer eating disorder diagnosis that didn't present when we were watching our ABC after school specials.
Nikki Kinzer:
Right.
Pete Wright:
I was going to say, nobody told me about that.
Dr. Jean Doak:
Yes. So it is newer. It's in the DSM-5. And what we are seeing, although it presents in adults, we're seeing a preponderance of it being manifested with younger children. And so we do see... There are three broad categories of ARFID that we are able to diagnose. One is around picky eating. So there are children who tend to be picky eaters and have a very restrictive food repertoire.
Another broad category is individuals who have sensory issues, so either taste, texture...
Pete Wright:
Texture.
Dr. Jean Doak:
... food colors. Again, that can lead to a very narrow range of food selection. And then the other category is hesitancy or fear of food intake as a result of some kind of traumatic episode. Oftentimes with children, it's a choking episode or severe allergic reaction. So those are the three broad categories of ARFID, but again, with the defining feature, it is a narrowing of food intake that can lead to nutritional concerns or failure to meet nutritional markers.
Nikki Kinzer:
So okay, I have a question because my daughter definitely falls into the first two, but it really went into restrictive eating, but I'm curious about that because when you talk about the picky eating, she doesn't want sliced cheese, it has to be shredded cheese. There's just so many rules around things, and she went vegan for a long time, which I've also learned with going through this process that it's not uncommon for someone with an eating disorder to go on these extreme type of eating plans.
Pete Wright:
Well, it sounds just like what you were talking about, exerting control, going on a restrictive dietary process is exerting a kind of control.
Nikki Kinzer:
Yeah. So I guess my question is there a difference between anorexia and ARFID, or is it just that's where that crossover is, is that there's just similar features. But anorexia, I can tell you at her lowest, I mean, it was very... you could physically tell something was wrong.
Dr. Jean Doak:
Yeah, no, you asked a fantastic question. There is a defining feature, although there are some overlaps. The defining feature for anorexia for example, is an intense fear of gaining weight.
Nikki Kinzer:
Okay, [inaudible 00:26:32].
Dr. Jean Doak:
And that is not present with ARFID. And so someone with ARFID could have all of this kind of narrowing or restrictive eating patterns, can fail to gain weight as they're a growing child or adolescent, but there isn't a fear of weight gain.
Nikki Kinzer:
Yeah, that makes sense. That's the connection. I mean, that was the overlap right there that kind of made her go over to the other side. Yeah, yeah.
Pete Wright:
Well, it's so interesting to me. I mean, I guess you don't have to look very far to find somebody who's affected with some relationship with some sort of eating disorder, particularly as you just described it. I mean, my uncle for years would not eat food that was not the color white.
Dr. Jean Doak:
Interesting.
Pete Wright:
He would eat rice and white bread and mashed potatoes, and he'd eat only white foods. Fruit, pears were good, but they had to be just right and he would peel the skin off, and also nothing could touch. And that was deeply into his 20s. And eventually he just figured... Something flipped. He just figured out. But I think if you go back and look at photos, I mean, now he's like 75 years old, but this was when I was a kid watching him. My parents would use him as a role model of how not to eat because he was...
Nikki Kinzer:
Oh, no.
Pete Wright:
... rail thin and because his choices were so limited, there's not a lot of nutritionally dense white food you guys, there's just not a lot.
But at some point, I'll use him, even though he was in his 20s, we've always said he kind of grew out of it. That feels like it diminishes what may have happened. So much of this ARFID that you're describing seems like something you'd see at really young kids, but eventually they figure it out and something a bit flips in their brain and they're okay versus the kids who don't and need intervention. How do you rationalize those things?
Dr. Jean Doak:
Yeah, I think that that is a fantastic question, and I want to go back to something that we were talking about at the very beginning of the podcast, and maybe for your uncle, for example, it is somewhat related to the degree to which it was interfering with day-to-day activities.
Pete Wright:
Okay.
Dr. Jean Doak:
I'll bring up an example. So oftentimes with children and adolescents, although it interferes with day-to-day activities, they're children and adolescents and they need assistance in navigating the world, so they need parents or an eating disorder expert to help expose them to a broader range of foods and challenge whatever perceived fears or worries that might be associated with eating those foods. That would be a way to target that behavior. Exposure is a skill or a tool that's used often with ARFID.
As an adult, I would imagine that if, for example, he was faced with this type of eating pattern interfering with his day-to-day activities, that probably limited his ability to eat at other people's homes, probably interfered with his ability to eat out at restaurants, or maybe eat with others outside of the family. And maybe that in of itself became a barrier that he wanted to work through.
Pete Wright:
At some point, there's an external pressure that exhausts his food anxiety.
Dr. Jean Doak:
Yes, exactly.
Pete Wright:
All right. That's fascinating, fascinating.
Nikki Kinzer:
So I want to talk a little bit about... We've talked about what it is, we've talked about the diagnosis, what does the treatment look like?
Dr. Jean Doak:
So a treatment... So I will say we talked about the five broad, not broad, the five categories or diagnoses of eating disorders. Each one has its own evidence-based treatment. But instead of going into great detail about that, because that might be just too detailed oriented, I'll probably talk about the two most commonly utilized evidence-based treatments.
One is called family-based treatment, and that is used for adolescents primarily with anorexia nervosa. And this is where the family or the parents and caregivers are put back in charge of feeding, re-feeding their child or adolescent. And there's a whole step-wise process to that. But the primary focus is initially is weight gain, symptom interruption, and behavioral stabilization. Those are the targets of treatment because we want to act quickly to limit or minimize the degree that there's medical compromise due to the weight loss. So that's family-based treatment.
The other evidence-based treatment is enhanced cognitive behavioral therapy, and it's predominantly used for adults with binge-eating disorder or bulimia nervosa. And there's evidence to be used with other eating disorder diagnoses, but this is more individually driven. It's a staged treatment. And again, the most immediate concern or target would be weight gain if needed. Not every eating disorder results with weight loss. I want to name that at the outset. And it would also be symptom interruption and behavioral stabilization. Those would be the targets for enhanced cognitive behavioral therapy.
And then I mentioned also with ARFID, there is that component of exposure, and the exposure's different depending on those three categories that I mentioned earlier, whether it was picky eating, like a narrow repertoire of foods, the sensory issues or the adversive episode, like a choking or an allergic reaction. We can target all three of those through exposure.
Pete Wright:
So on exposure, personal, disgusting story.
Nikki Kinzer:
Are you going to think about the OCD conversation?
Pete Wright:
No, but I should. And the toilet hands. No, we're not going to talk about that. This is-
Dr. Jean Doak:
Oh, I missed that.
Nikki Kinzer:
Yeah, that...
Pete Wright:
Thank goodness.
Nikki Kinzer:
But it's about exposure. It's those OCD...
Pete Wright:
Yeah, yeah, it's about exposure.
Nikki Kinzer:
... tendencies, yeah.
Pete Wright:
This is really interesting because I'm curious how you look at as a clinician when somebody comes to you... And I'm going to use quitting smoking as an example, and I've talked about this story before, so forgive me those of you who've heard this, but I think it's really interesting in this context. My dad was a smoker for a long time. He quit, and he replaced his smoking habit with food, specifically Butterfingers, and he ate them until he gained way too much weight, and the treatment for that was exposure. He went into the Pikes Peak quit center, and they put them in a phone booth and made him eat Butterfingers until he vomited into a trash can. And then he stopped eating Butterfingers, but he replaced that with other food.
As a clinician, you approach something like his maladaptive behavior with a specific food as something that sounds very much like he's on an eating disorder spectrum, but also addictive, right? He's found something to satisfy an addiction and now he's going in that direction. You were saying earlier how you sort of tease apart the... He also lived with undiagnosed ADHD until the day he died. So let's just throw that into the cornucopia of things that dad's living with. How do you approach something like that? And I'm thinking specifically for people who have those kinds of... we'll say like that Butterfingers sort of a fetish food. How do you approach something like that on this from the context of somebody who specializes in eating disorders?
Dr. Jean Doak:
If I think about ARFID, for example, and I think about those three broad categories of ARFID, what fuels or perpetuates the behavior is different in each of those categories, but fear, some underlying fear is probably related in all three. And so we drill down and really examine, well, what is that fear?
So for example, I'll bring up the choking or the adverse event, choking or allergic reaction. The fear is that if they eat a particular food or a food that approximates what that initial food was, that they're going to have an allergic reaction again or they're going to choke again. And so we work on that, and it either might be working on broadening the fruit food repertoire that looks more and more similar to that food, or maybe it's a size of food. Maybe we start off with a really small piece of that food and expose the individual to larger and larger pieces of the food.
But it's not just the exposure. When we work on exposure, we're also challenging what they think is going to happen. And so the more they're exposed and the less often the fear manifests, the more likely we can disconnect that link. So the more often they're exposed to the food and the less often they experience choking, the less often they experience an allergic reaction, we can disconnect that chain link. And so it is a progressive process.
Pete Wright:
What's so interesting about that, when I think about the behavior, my dad's behavior was they were able to make him quit smoking through extreme exposure until he was sick. He replaced that tool with Butterfingers. They made him stop eating Butterfingers, but he replaced that with M&Ms. I think what you're describing, they never addressed the fear that caused him to keep doing the things that he was doing maladaptively, and that was what he was really struggling with. They only addressed the symptom.
So it leads me back to something we were talking about related to OCD. How hard is it to treat somebody who's living with an eating disorder if they don't have a good handle on their ADHD? How does that impact their ability to overcome the more complicated sort of eating disorder behaviors that you're dealing with?
Dr. Jean Doak:
Y'all are asking just incredibly wonderful questions, almost like they're teed up, but they're not. So we were talking about, when I was talking about the biopsychosocial model and I was talking about the psychological or personality traits. When I think about the overlap of ADHD and some eating disorders, I think about the disorganization of the disinterest, the poor impulse control. So if that is not managed or effectively managed, I'll say that, and there's a co-occurring diagnosis, that's going to be really challenging.
The caveat to that though, I will say, is that for ADHD, what is the one thing that's utilized to manage that? It's a stimulant medication. What do we know about stimulant medications? They can suppress appetite. And so that could inadvertently either mask in the eating disorder or create an opportunity for disordered eating to shift over into an eating disorder. So it's this constant hypervigilance. You have to pay attention to everything.
Nikki Kinzer:
[inaudible 00:38:33].
Pete Wright:
And when you are dealing with living with a ADHD where you are attentionally constrained, fractured, that gets very, very complicated.
Dr. Jean Doak:
It does. And so sometimes we get very prescriptive when it comes to meals. So if somebody is really struggling with inattention, disorganization, impulse control, and is at best maybe going to be able to think about eating one meal a day, that's not going to cut it as far as eating disorder treatment's concerned. So we will be very formalized and say, "You need to have," as an example, "three meals per day plus two snacks, and these meals need to occur at this time, this time, this time. These snacks occur at this time and this time."
But as we all know, just saying that for an individual who has ADHD doesn't mean that that's going to translate into behavior. So we have to get further in our prescriptive process and say, "Okay, I said this time, what is going on in your day on a Monday at this time?" It could be very different than Tuesday. It could be very different than Wednesday. And then the weekends are all sorts of chaos because it's a lot less structure. So these are the things that we know. We know that an individual who has eating disorder needs a lot more structure, a lot more scheduling, a lot more monitoring in place in order for that prescription to even have a chance of occurring.
Pete Wright:
Wow.
Nikki Kinzer:
Yeah, it's interesting.
Pete Wright:
It's fascinating. How often or how common is it for somebody... You seem to have a, speaking of cornucopias, a real bouquet of experiences to be working so deeply in eating disorders and also have experience in ADHD. How often is it that... If you are wondering that you might need help in some of these areas, how often is it that you find somebody who has this sort of broad expertise, somebody who is working in eating disorders and understands ADHD?
Dr. Jean Doak:
It's not widely available, I'll admit. I think there aren't widely available clinicians who have expertise in eating disorders, I'll say that, and then probably even fewer to really understand and effectively manage co-occurring diagnoses along with an eating disorder. So it is a challenge. I think the first pass would be to be able to provide someone who has some expertise in eating disorders. And I could probably... I should have thought about this earlier, but I will send links to y'all as far as some resources that would be helpful for individuals and families to utilize if they're just wanting information about eating disorders or even if they want to try to find providers who can effectively manage and work with them in managing the eating disorder. I can certainly share those with you.
Pete Wright:
For those of us who have somebody in the family or somebody close to us who is dealing with an eating disorder, maybe they don't even know they have an eating disorder, but their behavior seems problematic. How do you recommend care or intervention, or is that a thing that you talk through?
Dr. Jean Doak:
Yeah, I think one of the challenges is family members often say, "Well, how do I know if this is something I need to ask them about? And even if I do want to ask them about, how do I ask them about it? What language or words can I use that are not going to be offensive or stigmatizing or hurtful?" And so interestingly, on one of the websites that I'll share with you, I think we have an infographic about words to use or helpful words to use. And so I'll make sure to highlight that as well because we never want any individual independent of whatever diagnosis may be on board to feel ashamed or embarrassed when someone is asking them questions or someone is expressing concern to them about their behaviors.
Nikki Kinzer:
There's a book that was recommended to me, it's really good called Sick Enough. And I thought that's sort of that question of is this person sick enough? And I know my question as a parent was always, how do we know if she needs to go into inpatient care? And that always scared me because I didn't know the answer. I still don't know the answer of when are they sick enough? And so that book helps, I think, puts things in perspective that really what you think is sick enough is a lot. They probably need the treatment a lot earlier than what you think.
Dr. Jean Doak:
Yeah, yeah, definitely. And we know this to be true. Earlier, intervention leads to better rates of recovery. So we would want everybody to have intervention sooner rather than later. But to answer your question about inpatient, when we think about inpatient for eating disorders, well, any inpatient provides the opportunity for 24/7 medical monitoring. And so when we think about that within the context of eating disorders, we think about to what degree are they medically compromised? And so we look at vital signs, for example. We look at their heart rate. We look at their blood pressure. We look at their temperature. We also look at their weight status, not just in an absolute current weight, the number on the scale, but how much weight they've lost or how much of a weight fluctuation have they experienced in a period of time.
And then sometimes, not sometimes, oftentimes we also look at lab values because if there's significant weight fluctuations, their lab values may be off. So these are all medical markers that if there's instability in any one of these areas, that would be an indication that inpatient would need to be utilized.
Nikki Kinzer:
Yeah, good to know.
Pete Wright:
Wow. This has been fantastic. Thank you so much, Jean, for joining us. Tell us a little bit about your work at Chapel Hill. What are you doing at the Center for Excellence for Eating Disorders?
Dr. Jean Doak:
Well, our clinic is housed within the Department of Psychiatry in the School of Medicine, and beautifully, we are actually on campus of UNC. So UNC is an interesting system where we have the university, we have the School of Medicine, and we have our clinics and hospitals all in one area. So I've worked in other academic medical institutions and that's not always the case. So we get to work with undergrads quite a bit, which is always lovely and always fun.
So my role is clinical director. I oversee our outpatient clinic in our inpatient unit, and we also have a very active research program and training program. So one of our missions is to provide training to emerging clinicians and to provide education and increase awareness around eating disorders.
And relatedly, I'm also deputy director of National Center of Excellence for Eating Disorders, which is one of the links I'm going to send you too. This is a grant-funded organization that we have, and I work in partnership with our director, Dr. Christine Peat. And all of our information is web-based. And so there's a plethora of information for healthcare professionals, families and caregivers, and patients themselves.
Pete Wright:
Fantastic resources. We will put links to that and everything you have just agreed to send us...
Dr. Jean Doak:
Great, great.
Nikki Kinzer:
Yeah, thank you.
Pete Wright:
... in the show notes when this show goes live. Thank you so much for hanging with us today and bringing us your wisdom. We sure appreciate it.
Nikki Kinzer:
And thank you for what you do.
Dr. Jean Doak:
Oh, it was my pleasure. And I really, I love the work that we do. I really do. And I can't believe we are already out of time. I feel like we could have talked for another hour or so.
Pete Wright:
Truly.
Dr. Jean Doak:
So happy to come back if there's...
Nikki Kinzer:
Oh, we would love to have you.
Dr. Jean Doak:
... another opportunity for a part two.
Pete Wright:
I am sure we can muster something up. I'm sure. Thank you everybody out there for downloading and listening to this show. We appreciate your time and your attention. Don't forget, if you have something to contribute to this conversation, we're heading over to the show talk channel in the Discord server, and you can join us right there by becoming a supporting member at the deluxe level or better. On behalf of Nikki Kinzer and Dr. Jean Doak, I'm Pete Wright, and we'll see you right back here next week on Taking Control: The ADHD Podcast.
