Episode 91: Dr. Case Halpern – Biology & Treatments For Compulsive Behaviors & Binge Eating | Huberman Lab

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Key Takeaways

  • Episodic therapy via deep brain stimulation delivered at the right time and only as needed at that time may be useful in treating obesity, addiction, and OCD to interrupt circuit dysfunction
  • Obesity is a phenotype often reflective of behavior – there’s a compulsion to overeat despite the risk
  • Development of eating disorders: (1) we’ve become a food-focused society – we’re really not meant to have constant stimulation of food; (2) there’s high fructose corn syrup in almost everything – processed foods rewire our circuitry to seek more; (3) recurring stressful event or life; (4) patients are embarrassed because society frowns on them
  • Right before people participate in binge eating, there’s a moment of feeling down or negative affect that they compensate for by binge eating or “loss of control eating”
  • Deep brain stimulation is currently being studied for use in binge eaters by provoking the craving during surgery and identifying the exact area of the nucleus accumbens where cravings occur – then delivering electrical stimulation
  • Anorexia, bulimia, and binge eating are all distortions in relationship to food where reward and habit are disrupted beyond control
  • Side note discussed: use power lifting and deadlifts specifically (with impeccable form, under supervision of trainer if needed) to profoundly improve strength & posture

Introduction

Casey Halpern, M.D. (@halpernc) is a neurosurgeon and Chief of Stereotactic and Functional Neurosurgery and Professor of Neurosurgery at the Perelman School of Medicine at the University of Pennsylvania. Dr. Halpern’s research and clinical practice focus on using deep brain stimulation to treat compulsive and movement disorders (e.g., binge eating disorders, bulimia, obsessive-compulsive disorder (OCD) and Parkinson’s disease essential tremor, dystonia)

In this episode, Andrew Huberman & Casey Halpern dive into deep brain stimulation, what it is, and its application for people who suffer from movement & compulsive disorders, as well as potential use binge eating, OCD, tremor, and anorexia. The future of these non-invasive brain stimulation technologies are also discussed for potential as therapeutic treatments for psychiatric illness, and much more.

Host: Andrew Huberman (@hubermanlab)

Deep Brain Stimulation And Its Applications

  • Deep brain stimulation (DBS) involves a procedure in which a wire is inserted in the part of the brain involved in the disorder then that wire is connected to a battery pack implanted in the chest and electrical signals are sent
  • DBS can be used for Parkinson’s disease and movement disorders to alleviate tremors but there’s also an added benefit of reducing impulse and depression in many patients
  • The outcome of DBS surgery for Parkinson’s disease and movement disorders is overwhelmingly positive – there are potential applications for DBS to be used for obesity, eating disorders, OCD, and mental health

Mechanisms & Traits Of Obsessive Compulsive Disorder (OCD)

  • The brain’s two main functions: (1) make sure biological systems are working properly; (2) predict what’s going to happen next based on knowledge of past
  • Cortical control areas don’t function properly in people with OCD, they’re often hyperfunctioning or hypo-functioning (it’s dysregulation of circuitry in either direction)
  • OCD is somewhat of a spectrum disorder – it’s possible to have some of the elements of the disease that are controllable or manageable, but on the other hand it can be debilitating if uncontrollable
  • Hallmark features of obsessive-compulsive disorder: intrusive obsessions, meaning the person doesn’t want to have them
  • Every time one engages in a compulsion (action) related to the obsession (thought), the obsession becomes stronger in a powerful and debilitating loop
  • Cortico-striatal thalamic loop: the circuits and loops active in OCD as identified by imaging studies – cortex (involved in perception and understanding what’s happening), striatum (involved in action selection and go-no go behavior), thalamus (relays and filters information from environment to brain)
  • Activation of cortico-striatal thalamic loop in rats without OCD actually generates persistent OCD-like behavior

Therapies For OCD

  • Therapeutic medications target the serotonin system (SSRIs) but it’s hard to predict how medications will work for each individual because the serotonin system doesn’t work alone – it’s also going to impact dopamine
  • Cognitive behavioral therapy: the goal of cognitive behavior therapy in the context of OCD is to uncover the underlying fear driving the OCD then take the patient to the highest anxiety point and disrupt the neural circuit between the processing and action parts of the brain to tolerate the anxiety and avoid the compulsion
  • Surgical option: ablation surgery on part of the brain that’s safe to destroy without side effects this can be controversial because the rate of success is about 50% so may be aggressive

Obesity, Binge Eating & The Brain

  • Not everyone with an eating disorder is obese and not everyone who’s obese has an eating disorder
  • Nucleus accumbens: part of the brain known as the hub of reward circuits – but it’s unclear what part (it’s almost 1 cm large which is big for brain space)
  • About 20% of people with obesity have a true “loss of control” like you see in addicts
  • Fatty foods can hijack the nucleus accumbens and encourage the behavior
  • There are promising trials in mice where manipulation of the nucleus accumbens shuts down overeating and seeking of fatty foods
  • Binge eating affects 3-5% of the population
  • Binge eaters usually binge once per day or 3-4 times per week (this is surprising for most people to learn) – there may be other big meals and “loss of control eating” that don’t qualify as a binge by definition
  • To meet criteria for “binge” you have to experience loss of control and eat an enormous amount of food at one time
  • Dysfunction leads to binging – both elevated autonomic arousal and decreased autonomic arousal
  • DBS is currently being studied for modulation of the nucleus accumbens (by identifying where the craving is originating by provoking craving during surgery) in obese people who have failed gastric bypass surgery

Anorexia

  • Anorexia is a disruption of reward processes: anorexics have a reflexive hyper-awareness about the fat content of food and default towards low calorie, low fat foods subconsciously and are rewarded by avoiding higher fat, higher calorie foods that sustain weight
  • Traits of anorexia: loss of muscle mass, low blood pressure, low heart rate, hair growth on the face, loss of bone density, loss of menstruation, disrupted gut and immune symptoms, high cholesterol, hyper-focus on details within environment, distortion of appearance versus reality
  • Anorexia, bulimia, and binge eating are all distortions in relationship to food where reward and habit are disrupted beyond control
  • Anorexia is more habit based while binge eating and bulimia cause food to be hyper attractive (like driving a car with no breaks)
  • Anorexia is the most dangerous psychiatric disorder because it has the highest mortality of eating disorders and mental health disorders, including depression
  • Anorexia overrides all homeostatic processes driving people towards food
  • Anorexia has a biological underpinning: anorexics feel good by approaching foods that are low fat, low calorie and rewarded more than if eating in a healthier way to support weight
  • Anorexia typically starts in adolescence when youth find food aversive
  • Males do suffer from anorexia, but women struggle with anorexia about 10x more
  • Rates of anorexia in the past 10-20 years are not increasing – and have actually stayed similar as compared to first discovery in the 1600s

Promising Non-Invasive Brain Surgeries

  • Transcranial magnetic stimulation (TMS): if done while patient is having intrusive thought, the stimulation can disrupt the compulsive behavior during and after treatment by intervening the automatic nature of OCD
    • There’s a lot of excitement about TMS in combination with SSRIs or CBT but it’s still early days
  • TMS has been FDA approved for depression
  • There may be a TMS target for eating disorders and anorexia in the future, but more research needs to be done to identify where needs to be targeted
  • Ultrasound is also FDA approved to deliver ablation to the brain, non-invasively – currently being used to treat tremor (essential tremor & Parkinson’s disease); in the future it’s possible you can open the blood-brain barrier to deliver medicine or treat mental health disorder
  • Ultrasound is being studied for obesity, addiction, depression, and other disorders; the focus is trying to find the right target to treat
  • Currently, studies are being done in which psychiatrists are triggering food craving under video surveillance and while connected to electrodes in attempt to identify the regions of the brain involved while watching visual cues in attempts to sync the timing

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