Comorbid ADD with an Eating Disorder

The most common dilemma regarding an eating disorder and the diagnosis of ADD is either distinguishing between the two or deciding someone has both diagnoses. 

Without even thinking about risks of the medications and ulterior motives in attaining prescriptions of stimulants, the clinician needs to take any concerns with attention, organization and memory seriously.

The central issue is a simple question. Is the eating disorder itself causing the cognitive symptoms or is underlying ADD the culprit? Ultimately, both situations are extremely common, and the answer is not always obvious and often takes a long time to answer definitively.

If a patient’s eating disorder is dominant, then the next best step is to hold off on the diagnosis. All eating disorder symptoms (restricting, binging, purging, laxative abuse, over-exercising, etc.) can have a significant effect on cognitive function that can mimic ADD. In this situation, it’s best to keep open the possibility of this concurrent diagnosis and instead focus on recovery.

If a patient has been previously diagnosed with ADD using Neuropsychological testing, then the diagnosis is not in question. It may not be appropriate to use stimulants yet depending on the state of the eating disorder symptoms, but it’s also critical to state that these two diagnoses can exist together and may in fact be correlated.

If a patient has improved significantly from their eating disorder and continues to have symptoms that could be ADD, then it is imperative that the clinician consider this diagnosis.

One option is to do Neuropsychological testing, but these results are not as reliable in adults as in children and can be prohibitively expensive.

Another option is to start a trial of stimulants and to monitor both food and changes in attention carefully. Stimulants work quickly at the correct dose and also can be diagnostic. When effective, they can aid in emotional stability and eating disorder recovery.

Although the steps in considering and diagnosing ADD are fairly clear when stated objectively, the nuances of the actual diagnosis are often more cloudy. I’ll start to look into these complications in the next post.

Eating Disorders and ADD, Overview

One particularly thorny diagnostic conundrum when treating people with eating disorders is the overlap with attention deficit disorder.

This diagnosis is particularly complex for many reasons. First, it has been diagnosed much more readily in the last decade after being misdiagnosed or under-diagnosed for generations prior. Second, the diagnostic criteria are for children, and diagnosis in adults is controversial and lacks any clear standard for the clinician to follow. Third, it has become in a patient’s interest to seek this diagnosis for accommodations in school and for so called “neuroenhancers,” known clinically as stimulants like Adderall and Ritalin.

The confusing clinical territory and incidental personal gain make the diagnosis and treatment difficult for any clinician to navigate.

However, when treating people with eating disorders, another added wrinkle is that these medications also can cause appetite suppression and weight loss as side effects. This fact makes these prescriptions very appealing to this cohort of patients.

Even more confusing, the diagnosis of ADD in patients with eating disorders is clouded by the fact that poor nutrition, binging and purging can all cause cognitive side effects that mimic ADD. Thus, the diagnosis is almost impossible to determine in an adult with an eating disorder unless the ADD symptoms started first. 

The final piece of the puzzle is that for ADD is actually the primary diagnosis for a small number of patients with eating disorders. And for these patients, treating previously undiagnosed ADD actually cures the eating disorder. The eating disorder symptoms actually managed the overstimulation and inattention common with ADD. Once treated, these patients no longer need the eating disorder to cope. Although this group is very small, it does mean the clinician can’t rule out undiagnosed ADD for any eating disorder patient.

Due to the complex relationship between eating disorders and ADD, I will use the next several posts to delve further into these issues and cover the following topics:

1. The diagnosis of ADD in the context of an eating disorder
2. The use of stimulants for people with eating disorders
3. Risk of abuse of stimulants in people with eating disorders
4. Use of non-stimulant medications for people with eating disorders who have ADD
5. Stimulant use as a neuroenhancer or party drug
6. Taking patients in recovery off stimulants
7. Indecisiveness, a common symptom of ADD and it’s role in recovery

The Internal Struggle Between Illness and Recovery

How can it be that eating and being nourished are the ways to recover and that eating and weight change feels so bad?

For almost all illnesses, the process of getting better also feels better. People often gain strength, feel more hopeful and can think more about their future.

Eating disorder recovery rarely involves a sense of forward progress. Eating many times per day, each day, for one day after another feels painful at first.

The sense of loss of not being able to engage in eating disorder behaviors is akin to losing one’s fondest pleasure, most effective coping strategy and a sense of accomplishment. Eating disorder symptoms wreak havoc on people’s lives and simultaneously give structure and meaning to each and every day.

So the steps of recovery are always conflicting and painful, never straightforward and easy. The ambivalence of giving up a foundational part of one’s life and identity is a slow death, agonizing but necessary.

Other ways of coping with life don’t also cause sickness, weakness and even death. Living with eating disorders means a much smaller life with much less room for relationships, intimacy and fulfillment. Although if may feel like a safer life, it’s also a sick and sad one.

This means that recovery means not only the struggle to eat each day and fend off the urges to do eating disorder behavior, but also saying goodbye to a life and to a way of surviving. It means giving up something that feels like a part of your identity and who you are. It means deciding it is worth learning how to live a full life and not settle for a sick and small one.

People do Recover Fully from an Eating Disorder

The most pervasive myth about eating disorders is that they are chronic and never go away. This falsehood has become even more widespread through the pandemic as it has been repeated widely on social media.

When unpacked, the myth reveals fears and untruths about the role of eating disorders of our culture.

The centrality of diet culture means that dissatisfaction with weight and body are extremely common and even dominant in many communities. So the concept of restricting food, the desire to lose weight and the virtue of being thin feel like facts to many in our society. As a result, many people who don’t have eating disorders and never did have constant thoughts about food and body.

Second, even though eating disorders are so destructive and severe for many people, these illnesses are still idealized. Anorexia especially is often seen as a triumph for people who have been able to overcome hunger and “control” what they eat. The truth of these disorders is very different.

Last, the explosion of residential treatment centers has diluted the powerful message many smaller programs used to convey. Centers focus on short-term health and treatment but rarely explain and reinforce what full recovery looks like. Thus, the end result of treatment is a partial recovery without further education about how to get better.

The crux of an eating disorder is the pervasive thought process about food and body that leads to compulsive behaviors and actions. These symptoms stem from inconsistent, insufficient eating so the body does not get the steady nutrition it needs to function. Without that sustenance, eating disorder thoughts grow and thrive.

To fully recover, the patients need to follow a meal plan, eat meals and snacks in adequate amounts and spaced through the day for months at a time. The body and brain need to learn that regular, nourishing food will be the norm again. Once that pattern becomes consistent, eating disorder thoughts will fade as life intervenes and becomes the focus of each day.

When this happens over time people get well. This is the truth about recovery. The myths above reflect a lack of understanding of these illnesses and the overvaluing of thinness.

Although the path to recovery is simple, the process of doing so is very hard, if not counterintuitive. Eating disorders are defined by abnormal eating patterns. Getting better means eating normally. I’ll explain this paradox in the next post.

The Role of Residential Treatment in Recovery

It has long been assumed by patients new to eating disorder treatment that a successful stay in an eating disorder residential program is essentially a cure. The buildup to admission, the hard work in the program and the culture of “Rez” introduce the concept that treatment will help you not get better but be cured.

Nothing could be further from the truth.

Residential treatment has many benefits, and the enormous increase in the number of programs across the country in recent years has improved access for many people who otherwise wouldn’t have options for inpatient treatment.

Treatment offers a safe place to learn how to eat again, nourish one’s body consistently for weeks or months and learn the skills needed to tolerate full stomachs, digestion and weight changes. For many people these steps are extremely difficult on an outpatient basis.

But residential treatment is also a bubble, an escape from the daily challenges of life. Work, friends, family and relationships all take a backseat while people are away. They can focus exclusively on recovery and the small world in the program.

No amount of preparation in that bubble can replicate the experience of being back in the world again. Even the most successful people in residential will find the urges and desire to return to eating disorder symptoms powerful after they get home. Once they experience the intensity of their emotions about the different aspects of their lives, everyone will feel the pull to rely on these symptoms, which have been a central coping mechanism for many years. Using new ways to cope is very challenging and takes time, learning and persistence.

What will improve outcomes and recovery after “Rez?” It’s a theme I have discussed many times in this blog, and here are the three main takeaways.

First, residential is the first step in recovery and in some ways the easiest. Don’t be tricked into thinking otherwise.

Communication between the residential team and outpatient team is crucial so that the transition is as seamless as possible.

Last, eat the food. Following the meal plan no matter what leads to people really getting better. That means completing the food log, being open and honest about any symptoms and seeking help and support at every turn.

Residential treatment is a critical part of recovery for many people. The more everyone understands its place in recovery, the more people can be successful.

A Clinicians’ Responsibility in Social Media

Clinicians, coaches and recovered people explain recovery work, spread knowledge and information and promote themselves on various social media platforms. The explosion of eating disorders treatment centers, normalization of these illnesses and isolation of the pandemic created space for many different voices in the eating disorder treatment world that everyone could access easily throughout the pandemic.

What’s confusing about all these new voices is the unfiltered nature of the noise. Social media algorithms attempt to keep you on the platform. There is no way to filter all the information to spread informed, knowledgeable or even true ideas.

Many people caught in the eating disorder web on social media find themselves trapped and often convinced of the ideas presented to them over and over again. If the message is about recovery and the harm of eating disorders then that’s great. If the message is about identifying fat phobia and body positivity then that’s important too. But it’s equally likely the message will be diet focused or even pro eating disorder. Without any way to filter out the destructive or false messages, the risks of developing an eating disorder or relapse only escalate.

These concerns are pervasive effects of social media in our current culture from politics to health to the pandemic. However, the increased incidence of eating disorders in the last year and a half shed light on how dangerous this messaging is and how clinicians need to be aware of the risks.

Treatment, in all different forms, needs to incorporate a strategy to include the concerns around social media. And clinicians using social media to promote themselves need to be careful how and in what way they are seen. The lines have blurred between treatment professionals, coaches, influencers and social media stars. As much as possible, clinicians need to try to distinguish what they do and why it’s different.

The best way to support recovery in this world is to remember that self-promotion can’t be the main goal. Any social media presence for a clinician can include links to their own practice and treatment goals but also needs to be sure to point people towards real, proven information about eating disorders, treatment and recovery.

No matter how much our online presence melds with advertising and personal brand, every clinician needs to remember that treatment and helping others is the top priority.

The Role of Social Media in Eating Disorder Recovery

So many people with new eating disorders or relapses had nowhere to turn for help during the pandemic. Society shut down as we know it and access to any mental health care was severely curtailed. The eating disorder treatment world, like all health care, became instantaneously virtual with no warning and no plan. Assessment, treatment planning, residential care and outpatient treatment programs scrambled to adjust but left patients minimal options for true care.

The incidence of new eating disorders skyrocketed, but patients couldn’t find help. Clinicians had endless waitlists. Virtual programs struggled to function because eating with people in a safe setting is central to the effectiveness of treatment. Residential programs had trouble even staying open and accepting new people safely.

So many people stayed home, trapped by the coronavirus, trapped by their eating disorder, alone and scared.

Home as well, clinicians, coaches and recovered people looked for new ways to attempt to help. The plethora of Instagram dietitians, body positivity influencers and recovered people had already had an enormous impact on the vocabulary and approach to eating disorder treatment. That burgeoning world exploded during the pandemic and added TikTok as an equally powerful platform.

But the increased exposure to recovery oriented content came with the algorithms intended to push people, especially teenagers, towards posts that encourage extreme dieting, low self-esteem and thereby increased the risk of eating disorders. Research data presented to Congress this week by a former Facebook executive provides incontrovertible evidence about the destructive effects of Facebook and Instagram.

The lay of the land in the eating disorder treatment world has been forever changed.

These social media voices express a varied, powerful and resonant chorus about eating disorders, body image and recovery which all clinicians must now heed. The messages previously attributed to older media outlets are no longer easily avoidable but instead in our hands and on our screens all day long. Ignoring this new reality means missing the basic understanding of how eating disorders now exist in our culture.

Let’s hope that the experience accelerated by the pandemic and by the exposure of Facebook’s destructive business decisions help avoid an even larger uptick in eating disorders. As clinicians, we need to discuss social media as a realistic outlet to aid in recovery. Focusing on the ways to use content to encourage recovery, reinforce positive messages about body image and self-esteem and avoid triggering images and diet advice is crucial. It’s imperative for clinicians to work with this powerful tool and not demonize it or ignore it.

The next post will venture into trickier territory. What is the role of clinical work in the social media universe? Where are the boundaries between helping people get better and self-promotion?