When Katy Weber, a health coach who works with patients with binge eating disorder, was diagnosed with attention deficit hyperactivity disorder (ADHD) at 45, some of her major struggles in life started to fall into place. Weber, who developed binge eating disorder as an adult, quickly realized that a significant portion of her challenges around food—like failing to recognize hunger cues—were related to having ADHD. “It makes so much sense once you start connecting the dots,” Weber says.
Although there’s still a lot we don’t know about the connection between ADHD and binge eating disorder, there is a high degree of overlap between the two conditions; an estimated 30 percent of patients with binge eating disorder also meet the criteria for ADHD. As ADHD diagnoses have increased in recent years, especially in adult women such as Weber, many are starting to realize some of the ways in which their disorder increases their risk for developing other comorbidities.
“Like so many of these issues, it’s multifactorial, and it’s also somewhat person dependent,” says Carolyn Lentzsch Parcells, a pediatrician in Texas who specializes in treating patients with ADHD and eating disorders. “Just like every single person with ADHD is different, every single person with an eating disorder is different.”
The role of impulsivity
Binge eating disorder, which is defined as habitually eating large amounts of food in a short amount of time, is characterized by out-of-control behaviors, including feelings of shame or remorse. Patients with binge eating disorder will often report eating beyond a feeling of fullness, to the point that it becomes a compulsion to keep eating, in spite of a desire to stop, and in spite of intense feelings of embarrassment or regret. “It’s more an impulsivity issue,” says Cesar Soutullo, a psychiatrist at UTHealth Houston who specializes in treating ADHD. “Once you start, you cannot stop.”
ADHD is a neurodevelopmental disorder that affects the parts of the brain that controls executive function. People with ADHD have difficulty planning, differentiating high versus low priority tasks, recalibrating plans due to last-minute complications, and completing long-term plans. Some of the symptoms of ADHD also include an increased susceptibility for addictive behaviors.
The two conditions intersect when patients born with ADHD develop a binge-eating disorder later in life, often due to a mixture of genetic and environmental factors. The complex connection between binge eating disorder and ADHD is due to several factors common in patients with ADHD, such as difficulties with emotional regulation, impulsivity, and reward processing.
As a number of studies suggest, the link between these disorders is also thought to be related to the ways in which the brains of people with both conditions process rewards.
For people with ADHD, “our reward processing center does not process rewards like your average bear,” Lentzsch Parcells says, who was diagnosed with ADHD at the age of 17. “We seek reward differently, but we also respond to reward differently.” For people with ADHD, their brains respond less intensely to rewards, which means they need a much larger reward to become motivated, compared to their peers without ADHD. For people with binge-eating disorder, studies suggest that they respond more intensely to the reward of food than others.
When the reduced response to rewards in general that is seen in ADHD is combined with a heightened response to food in particular, this can create a situation where food becomes a way to self-medicate. Given that people with ADHD are often under-stimulated, which leads to low motivation, eating can turn into one of the very few activities that feels rewarding. “In the short term, it works,” says Sarah Greenberg, a psychotherapist with the organization Understood.org, which offers resources for people with learning differences, such as ADHD. “You get that dopamine hit, you get that sense of reward.”
For Weber, the link between the two disorders has been a complex one, one that ties into a number of food-related issues that commonly plague people with ADHD. This includes a pattern of forgetting to eat until she was starving—which would often lead to over-eating—and difficulties with staying organized enough to eat three balanced meals a day. She also tends to swing between two extremes in diet: a highly restrictive diet or out-of-control binge-eating.
Weber also has always had trouble recognizing her hunger cues. That’s common for many patients with ADHD, who report a lessened sense of bodily awareness. “That’s why a diagnosis feels so profound,” Weber says. “It’s an opportunity for us to realize that there is a why [we binge-eat].”
How does treatment work?
Treating patients with multiple disorders can get quite complicated, as clinicians have to figure out which disorder should be treated first. This can be a tricky balancing act, as the order in which comorbidities are addressed can make a big difference to whether the treatment is successful.
For example, treating ADHD in a patient with untreated bipolar disorder can increase the severity of their bipolar disorder, while there is some evidence suggesting that treating ADHD concurrently with substance use disorder can lead to lower rates of relapse. “You want to treat one disorder, without making the other worse,” says David Goodman, a psychiatrist at John Hopkins University, whose research focuses on ADHD.
For patients with ADHD and binge eating disorder, this question is more straightforward than most, as the one FDA-approved treatment, a stimulant medication called Vyvanse, also works for ADHD.
Other, smaller studies suggest that ADHD medications such as the non-stimulant drug atomoxetine or the long-acting form of the stimulant medication methylphenidate can help reduce the frequency and intensity of binge eating episodes.
“If you treat the ADHD, you reduce the frequency and intensity of binges,” Soutullo says. But finding the right treatment and dose can be tricky. A number of patients will report an increase in binge eating episodes if they are put on the short-acting forms of ADHD medications, as the appetite suppression side effects can lead to a pattern of forgetting to eat, followed by over-eating.
In practice, the connection between the two disorders, and the ways in which the presence of both might affect treatment are not always recognized. “There are misconceptions about ADHD and there are misconceptions about eating disorders,” Lentzsch Parcells says. “When you put them together, that is a population that is really, really underserved.” For Greenberg, who was diagnosed with ADHD at the age of 14, and developed an eating disorder later, the connection between the two were not recognized during her treatment. “These conditions are seen as separate entities,” when in reality, Greenberg says, “there’s so much overlap.”
Many patients struggle with behavioral strategies
For behavioral therapies, having ADHD can complicate recovery from binge eating disorder, as many patients wrestle with staying organized and creating the structured environment. “In terms of behavioral treatments, so often it begins with consistent meal plans, and eating consistently,” which is incredibly hard for people with ADHD, Greenberg says. “What happens when that structure goes away?”
As Greenberg notes, many of the commonly offered treatments and strategies for eating disorders are not designed for patients with ADHD, who commonly have trouble with organization, focus, and time management. This can make the process of recovery much harder, especially as an outpatient.
In the years since Weber received a diagnosis of ADHD, it’s has given her a better appreciation for the overlap between the two conditions. It’s also given her a greater empathy for the patients she works with, many of whom also have ADHD. Given what she’s learned, she’s starting to recognize patterns in her patients, such as difficulties with maintaining structure, that have also hindered her own recovery. “Everything comes back to this diagnosis in a way that is so profound.”