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A new phase II trial, STOP (Study of the Treatment of Overeating Using Psilocybin), is currently underway to determine the efficacy of psilocybin candidate TRP-8802 in combination with psychotherapy for the treatment of binge eating disorder (BED). To learn more about this research, 

™ sat down with Jim Gilligan, PhD, MBIS, the chief science officer and interim CEO of Tryp Therapeutics.

PT: Can you say a bit more about the aim of the study and how TRP-8802 might change treatment for individuals with BED?

 The use of psychedelics in conjunction with psychotherapy provides clinicians with a tool to reach deeper into the patient’s subconscious and potentially gain a better perspective on what is driving the aberrant behaviors with respect to eating. Overeating disorders can be viewed in part as addictive behavior relating to food.Psychedelics and psilocybin, in particular, have shown benefit in treating patients with addictive behavior.

In addition, patients with BED often also experience anxiety around food and depression, which might be considered comorbidities. Psilocybin has also shown promise in patients with both anxiety and depression. It is important to recognize that a change in the patient’s behavior is of paramount importance. For instance, a significant portion of patients that seek bariatric surgical intervention achieve an immediate benefit, but over time gain back weight because their behavior towards food has not changed. The neuroplasticity potential of psilocybin, in conjunction with psychotherapy, has the potential to “rewire” these behaviors and improve the patient’s behavior toward food.

PT: Why specifically BED? Do you think this could have an effect on eating disorders as a broader category?

Binge eating is typically viewed as a loss of control type of eating disorder that is extremely socially limiting and causes feelings of guilt for the individual. These characteristics make it an ideal candidate for psilocybin therapy for eating disorders, as it has been shown that psilocybin can help other “loss of control” psychiatric issues, like OCD and alcoholism. Binge eating is the most prevalent eating disorder, and many experts have noted that it is underrecognized and undertreated. What we learn about psilocybin assisted therapy in BED could have relevance for other eating disorders. There is some overlap in clinical presentation such as body dissatisfaction as well as links to histories of trauma in some patients with eating disorders.

There is a level of commonality among the different eating disorders, and we believe that psilocybin treatment in conjunction with psychotherapy could have a positive effect on other types of eating disorders. Psilocybin is also currently being examined in clinical programs in patients with anorexia nervosa.

PT: Approximately 10 million boys and men in the US will experience an eating disorder at one point in their lives. How do you think this research will specifically impact men/boys?

Binge eating is the most common eating disorder among men, so this research may have special relevance to this population. Our study will include men with binge eating disorder, so hopefully, the results will be able to be generalized between sexes and not limited to males or females exclusively. Psychedelics have never been tested in BED for men or women previously. These preliminary results will hopefully provide useful information for future studies that examine this topic more closely.

PT: What are some of the differences in presentation/symptoms among the sexes, and how does psilocybin impact those?

Men tend to be more secretive and in denial about binge eating, so it is a bit more difficult to get them to be open to change and forthcoming about what is going on in their lives. Psilocybin can potentially make them more open to dealing with the issue internally and more accepting of therapy.

This denial by men may also partially account for why there is a greater prevalence of BEDs in females than males (about a 2:1 ratio). However, there are more similarities than differences in clinical presentation across the sexes. We do not know yet how psilocybin impacts clinical presentation and other outcomes across the sexes, but hopefully, the current research will set the stage for larger studies.

PT: Both psilocybin and eating disorders, especially in men, unfortunately, carry a stigma. Do you think this new research can help lessen that stigma?

Hopefully, this research will reduce the stigma. Again, both sexes are being studied in this study. The research may help change the view of psilocybin in general to one that sees it as medicine or curative. This research, in combination with the rapidly expanding field of psychedelic science, may go a long way towards reducing this stigma.

PT: What about the issue of dosage? With orally administered psilocybin, there can be a thin line between a clinical dose and a bad trip.

Tryp recognized early on the variability in response to orally administered psilocybin. Published pharmacokinetics results revealed that even when administered on a weight-adjusted basis (mg/kg), there was up to a 4-fold range in blood levels which could contribute to some individuals not achieving a meaningful psychedelic experience, while others had a “bad trip.” Other deficiencies associated with oral administration include the lapse in time between oral dosing and the start of the psychedelic experience, which can take up to 2 hours, and the length of the trip, which could be another 6 to 8 hours and can potentially be burdensome to the patient and clinicians alike.

There is a safety-related issue as well with oral dosing. There is a “loss of control” of the oral dosage form, meaning once you take the capsule you lose control over what will happen should there be a safety concern. TRP-8803, which is Tryp’s proprietary psilocybin, addresses all of these limitations. TRP-8803 has the ability to induce the psychedelic state within ~30 minutes while accurately targeting blood levels known to induce the psychedelic state, is also shown to be safe, and has the ability to control the length of the experience and terminate if necessary.

PT: What should clinicians know about the use of psilocybin for treating patients with binge eating disorder?

The results from this study may help inform clinicians in the future on the potential role of psilocybin in conjunction with psychotherapy in the treatment of BED.

is the chief science officer and interim CEO of Tryp Therapeutics.

This new study is evaluating how effective psychedelics can be in the treatment of binge eating disorder. 

Psychedelics for the Treatment of Binge Eating Disorder in Males

Tales From the Clinic: The Art of Psychiatry

, we discuss a case of bulimia nervosa and the challenges of managing it in outpatient care. Eating disorders (EDs) include pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa (restricting type/binge-eating/purging type), bulimia nervosa (BN), and binge-eating disorder. Growing awareness of disordered eating is helpful in conceptualization and treatment, and it covers the gamut from grazing and excessive dieting to frequent weight fluctuations and other behaviors that do not warrant a diagnosis of eating disorder.

“Ms Georgina” was referred to the outpatient clinic following recurrent compensatory behaviors without remission. One look at Ms Georgina’s chart, and the complexity of her ED presentation became apparent and almost overwhelming. Diagnosed with BN at age 14, Ms Georgina had been unable to establish residential/inpatient care due to a plethora of barriers (ie, insurance denials, lack of resources, bed availability). She had a tumultuous clinical history of recovery (verbalized), relapse, hospitalization, and failed medication trials.

At the time of treatment initiation, Ms Georgina was living with her immediate family and working at a nearby community center. She endorsed a binge-purge cycle occurring 1 to 2 times per day (depending on mood) that began with purchasing large amounts of food on the way home from work, eating the food in her room, and vomiting it into a trash bag. As one can imagine, this presentation of BN is quite advanced and has deep-rooted anchors in personality and day-to-day functioning that appear to go far beyond body image and comparisons. During the first interaction, she appeared sullen and fatigued, attempting to hide much of her appearance during the session and subsequently remained relatively quiet. Ms Georgina was forthcoming and accepting of psychoeducation and clinical interview questions. She demonstrated an adequate amount of insight and voiced a need for help: “I am not an idiot. I know this cannot keep going much longer. I know this… trust me, I know.”

Ms Georgina described her childhood as “scattered” and discussed difficulty with familial interactions from an early age. She expressed a history of constant moving, divorce, and remarriage of both parents. She denied abuse of any type. Her anxiety symptoms began around this time, at age 9, with specific localization in her abdominal region. Ms Georgina said, “it would only go away when I ate and forgot about the feelings.” At age 13, she recalled a distinct memory of being called “chubby” by her family; shortly after, she had a relationship end due to her being overweight. She was highly emotional while speaking about this event and profusely stated, “this is where it all began. I do not know what it was about how he ended things, but looking back, this is where it turned to shit.”

Ms Georgina began restricting meals and increasing the frequency at which she worked out. A friend introduced laxatives to her, which also became a part of this almost daily routine. Binging/purging emerged as she entered high school, as a way to maintain relationships and enjoy outings, but also maintain control over her body image. She reported that her binge/purge episodes only occurred every weekend, but slowly increased in prevalence until the episodes were daily. Persistent laxative use led to gastroenteritis, hypokalemia, and esophagitis at age 18. Family members commented on her behaviors, but Ms Georgina described herself as so “engulfed” by her routine at this point, that she did not recall serious conversations about medical/psychiatric help.

However, she did recall an instance on a family trip in which her family caught her in the act of purging, and she was taken to a general practitioner upon returning. She was prescribed Zoloft and Xanax to help with her diagnosed generalized anxiety disorder, which led to a subsequent overdose at age 19 (accidental, per patient). Subsequently, Zoloft and Xanax were discontinued, psychiatry restarted Zoloft, and she maintained adherence for 1 year before stopping medications and disregarding follow-up appointments. She denied past individual psychotherapy, group therapy, or residential treatment. Ms Georgina stated that her insurance would not cover residential treatment, and she had been turned away previously at intake. Ms Georgina denied past or present suicidal ideation; however, she did endorse a sporadic history of passive thoughts of death.

BN diagnoses have steadily risen over the past decade, contributing to an estimated 6.3 million Americans currently meeting criteria. Moreover, if not thoroughly screened, BN is shown to be consistently underdiagnosed by mental health providers due to a myriad of reasons. Research indicates that initial screening and questionnaires use may be too rigid to accurately identify compensatory strategies, medical complications secondary to EDs, and differences in presentation (child/adolescent/adult).

Particularly with BN, studies demonstrate that weight changes may prove to be insignificant, which can allow BN to go undiagnosed for longer periods of time when compared to 

, avoidant/restrictive food intake disorder, and binge-eating disorder. This is particularly true for early detection and intervention, which may significantly impact prognosis and treatment for common medical comorbidities (low bone mineral density, growth retardation, disturbed metabolic rates).

 A combination of structured and unstructured questions may be useful in conjunction with a short screening tool, similar to the Sick, Control, One, Fat, Food (SCOFF) questionnaire.

 The SCOFF can be administered orally or in written form, and it provides simple, straightforward answers. Due to the generality of the questions, only 1 positive answer indicates that further information may be required.

If BN is suspected, structured interviews, following specific DSM-5 criteria is useful. These questions should most definitely encompass the mainstay of BN, which is binge eating, and accompanied by specific questions regarding self-control during binges; feelings of guilt, remorse, or shame; and other compensatory behaviors (over-exercising, laxatives, enemas, stimulant abuse). Further inquiry into specific patterns of binging/compensatory behaviors can provide determinants related to severity and duration of disorder. Mood states pre- and post-cycles, binge triggers, context-specific behaviors, family patterns/interactions, mental health history, and food perceptions are essential to gauge.

Treating advanced disordered eating on an outpatient basis requires in-depth background history and awareness of current literature. Differential diagnosis and clarification are imperative steps in this process, and many of the eating disorders outlined in the DSM-5 share similar criteria. Furthermore, compensatory behaviors and types of eating patterns have recently been identified as pervasive, albeit sub-clinical, disordered eating (ie, grazing, loss of control eating).

 Another consideration is identifying a medical presentation that may be indicative of BN. The following symptoms should warrant further consideration if identified in conjunction: energy despite cachexia, gastroesophageal reflux disease (GERD), dehydration, gastrointestinal distress, subconjunctival hemorrhages, Barrett’s esophagus, cavities/dental erosion, acrocyanosis, Russell’s signs, and abnormal lab values.

 Open communication with medical providers, nutritionists, and nurse case managers is highly encouraged to help streamline treatment protocol and recommendations. Most often, these are unavailable or patients may be unwilling to adhere to recommendations outside of psychiatric treatment.

Although BN is often construed as a “less severe” ED, mortality rates have been observed as equal to or slightly below 

. Moreover, an increased risk of suicide is positively correlated with the severity of presentation. These 2 considerations alone make this diagnosis difficult to treat from an outpatient perspective if a complete background and open line of communication are not established early in treatment. Safety planning, instillation of hope, and immediate introduction of adaptive coping skills are necessary components to the early treatment process and especially imperative when treating well-established eating disorders on an outpatient basis. This step clearly details safety concerns and ensures there is a mutual understanding of the medical risks associated with disordered eating.

Early sessions with Ms Georgina focused primarily on understanding core mechanisms and insight into presentation. Much focus was given toward empowering the patient to think critically about her life course and identify contributory factors to the development of BN. CBT-Enhanced (CBT-E) explicitly states to begin to narrow and personalize the treatment protocol toward the patient; in Ms Georgina’s case, this occurred rather quickly, as she had entered therapy highly motivated and fearless of retrospective analyses of behaviors, experiences, and thoughts. An internal diagram was constructed with Ms Georgina to concretely display a conceptualization of her ED, which was characterized by negative familial interactions, bullying, and forced body comparisons that led to an overall low self-esteem and dissatisfaction with self. Her shame toward self and eating patterns dominated the early sessions, and time was devoted to discussing the overlap between self-shame, culturally reinforced body shame, and the mediating factors of guilt, dysregulation with food, and binge-purge cycles.

As the function of Ms Georgina’s ED became increasingly clear, gentle challenging with complementary coping skills were introduced. Mindful eating and nutritional psychoeducation provided the framework for restructuring her relationship with food. Hunger/fullness cues, intention settings, breathing exercises, mindful distraction, and appropriate challenging were instrumental skills to master prior to collaborative reduction of 

. It is imperative to maintain open communication and consistent symptom/behavior tracking during this stage to appropriately gauge progress. Cognitive distortions were continuously brought to awareness and normalized, and a combination of rational thinking and behavioral experiments were utilized to help disconfirm distortions and birth new alternative beliefs. Ms Georgina is currently in the final phase of treatment, which is placated on preventing relapse and ensuring that changes are maintained over time. The focus is on the future, and it heavily reinforces the new belief system, mindful eating strategies, and coping skills to decrease distress/anxiety.

 can be quite challenging at each level of care—particularly in an outpatient clinic. Recent studies have sought to identify which modalities are effective and generalizable to a variety of presentations.

 Cognitive behavioral therapy-bulimia nervosa, cognitive behavioral therapy-enhanced, interpersonal psychotherapy, and dialectical behavior therapy, among others, have all had considerable attention and shown some effectiveness in decreasing problematic symptoms. The decision of which to use should factor in resources, time availability, level of care, and provider familiarity. CBT-E offers a time-limited directive approach that aims for improvements in severe ED psychopathology, body mass index, remission rates, and suicidality.

 Moreover, De Jong and colleagues speculated that CBT-E may be a cost-effective modality that provides the ability to offer treatment in settings with limited psychiatric resources, subsequently increasing the reach for specialized psychiatric treatment to underserved populations.

 Support and structure are critical for long-term remission, soothing painful feelings, and creating a stable sense of self over time.

 is a psychology fellow at Baylor College of Medicine. 

 is an assistant professor and licensed clinical psychologist at Harris Health System in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine in Houston, Texas.

1. Gravina G, Milano W, Nebbiai G, et al. 

Medical complications in anorexia nervosa and bulimia nervosa.

2. Westmoreland P, Krantz MJ, Mehler PS. 

Medical complications of anorexia nervosa and bulimia.

The SCOFF questionnaire: assessment of a new screening tool for eating disorders. 

Screening for symptoms of eating disorders: Reliability of the SCOFF screening tool with written compared to oral delivery. 

Emotion regulation and binge eating in children. 

Grazing and loss of control related to eating: two high-risk factors following bariatric surgery.

Eating disorders in children and adolescents: state of the art review.

8. Hay PP, Bacaltchuk J, Stefano S, Kashyap P. 

Psychological treatments for bulimia nervosa and binging.

A systematic review of enhanced cognitive behavioral therapy (CBT‐E) for eating disorders.

10. de Jong M, Korrelboom K, Van der Meer I, et al. 

Effectiveness of enhanced cognitive behavioral therapy (CBT-E) for eating disorders: study protocol for a randomized controlled trial.

How can you help patients with bulimia nervosa beyond residential programs?

Trust, Patience, and Communication: Treating Bulimia Nervosa When Residential Programs are Unavailable 

Conjure up an image of someone with an eating disorder.

If I had to guess, she’s a young, emaciated, white, cisgendered, heterosexual female from a middle- or upper-class family. Maybe she is a dancer; perhaps she gets straight As in school. Her family might have trouble expressing emotions. Maybe her mom was chronically dieting while she was growing up.

Now, imagine you are sitting in a lecture hall back in undergrad—one of those large ones with 300+ students and a teacher at the bottom of the stadium-like room that you could barely see.

Did anyone in that room look like the girl you conjured up? Maybe yes, but more likely than not, the answer is “no.” In that room were likely bodies of all shapes, sizes, and genders. And in that room, there were individuals with 

Eating Disorders: Misconceptualized and Stereotyped

Until relatively recently, stories of eating disorders seemed to exclusively center on what has been stereotypically depicted as the “classic eating disorder.” Typically, this affects exactly the type of individual we conjured up earlier—a young, emaciated, white, cisgendered, heterosexual female from a relatively affluent background. Movies like 

 with Lily Collins and stories from celebrities ranging from Karen Carpenter to Tracey Gold have grabbed our attention for years with their dramatic 

Despite greater awareness of eating disorders in the United States, the types of individuals who experience eating disorders remain largely misconceptualized and highly stereotyped, leaving out most of those who struggle. Males, individuals of color, and those in the 

 are both less likely to be diagnosed and more likely to face significant barriers to accessing treatment for their eating disorder when/if they come to clinical attention. Eating disorder signs and symptoms themselves are consistent across gender, age, racial, ethnic, and sexual orientation groups. Despite similar rates of eating disorders among non-Hispanic whites, Hispanics, African Americans, and Asians in the United States, people of color are significantly less likely to receive help for their eating issues.

Although risk factors themselves may differ across minority populations based on factors more unique to specific groups, the types of behaviors individuals engage in remain consistent and fall into 3 basic categories: restricting, 

, and compensatory/purging behaviors. The dominant behaviors, frequency, and intensity of symptoms are what generate specific diagnoses, and it is not at all uncommon (in fact, it is fairly common) for individuals to vacillate between disorders as behaviors vary in dominance over time.

The Unique Challenge for Minority Populations

Individuals of color and those in the LGBTQ+ community often face unique challenges that may place them at greater risk for developing eating disorders. Research suggests that starting at age 12, gay, lesbian, and bisexual teens may be at higher risk for binge eating and purging compared with their heterosexual peers.

 Black and Hispanic teens have a higher prevalence of disordered eating patterns compared to their white peers.

The risk factors, stereotypes, and stigma associated with minority populations regarding weight, body image, and dieting contributes to these groups experiencing significant hurdles in accessing care and ultimately overcoming their eating disorders. Individuals of color, male-identifying individuals, and those in the LGBTQ+ community are less likely to seek treatment in the first place, often related to cultural barriers, fear of rejection, and discrimination. Many in marginalized communities do not access care due to not fitting the cultural stereotype and fearing that others may not take their illness seriously.

Indeed, health care professionals themselves are less likely to ask those in minority populations about eating disorder symptoms due to bias. In 1 study, when clinicians were presented with identical cases demonstrating disordered eating among white, Black, and Hispanic women, clinicians were more than 50% less likely to identify the Black woman’s behavior as problematic and recommend she should receive professional help.

Minority populations may face greater adverse life experiences including trauma and homelessness, among others. They are more likely to have public insurance or to be uninsured. In the increasingly privatized sector that is eating disorder treatment, this can make accessing care nearly impossible for those in marginalized and/or minority communities. The existence of academically affiliated, community-centered health care programs with expertise in eating disorders are few and far between in the United States, making it less likely that those on public insurance and those who are uninsured can even access care in the first place.

What Type of Person Has an Eating Disorder?

Although eating disorder awareness has improved in the United States, there still seem to be many misconceptions regarding the types of individuals who have eating disorders.

When marginalized individuals develop eating disorders, it is often not due to a desire to be thin. After all, eating disorders are not solely about food or thinness. Eating disorders go much deeper than that. Stereotypes such as “gay men are all muscle or thin” and “all individuals with 

 are malnourished” prevent individuals from seeking help. Other common barriers to treatment in the LGBTQ+ community include a lack of culturally competent treatment, which addresses the complexity of unique sexuality and gender identity issues, lack of support from family and friends, and insufficient eating disorders education among LGBTQ+ providers who are in a position to diagnose, treat, and/or refer. Additionally, individuals in the LGTBQ+ community experience unique risk factors that can cause them to face challenges when accessing treatment and support including fear of rejection, experiences of violence which increase vulnerability to an eating disorder, discrimination based on sexual orientation or gender identity, being victims of bullying, discordance between biologic sex and 

, and inability to meet body image ideals within some LGBTQ cultural communities.

In many cultures, specifically the Latinx culture, love is often shown through food, with women being raised to learn to cook and care for the household, while men are raised to make a living and support the family financially. This split can create a sense of isolation for women and men as they learn to put others’ needs first and do not ask for help, which can make seeking care difficult in this situation.

Asian Americans and Pacific Islanders (AAPI) are often part of close-knit communities who shun signs of weakness and negative emotions. As such, disordered eating may be pushed aside due to the stigma of it representing “weakness.” Individuals in this community often come from achievement-oriented families with high parental expectations, which are correlated with high rates of perfectionism—a predictor of 

, in particular. Admitting that one needs help in this community may be seen as a sign of weakness and exude fear and shame from families, thus further inhibiting access to care and treatment.

Most tools developed to screen for and assess eating disorders were developed among groups of young, white females. Males/male-identifying individuals have often been excluded not only from research, but also by treatment settings that historically have catered to the young female demographic. People of color with self-reported eating and weight concerns were significantly less likely than white participants to have been asked by a doctor about eating disorder symptoms, despite similar rates of eating disorder symptoms across ethnic groups.

 Eating disorders are not screened for universally in primary care or psychiatric settings. As a result, they are often missed, unless patients from stereotyped backgrounds/with classic presentations come to clinical attention.

I have worked with individuals from the Black community who have had gastric bypass surgery while actively struggling with an undiagnosed eating disorder—not because the symptoms were not there, but because no one asked. These individuals now struggle not only with their eating disorder, but with the sequala of a surgical procedure that was not indicated. One individual I recall working with—a Black middle-aged, lesbian woman with a severe trauma history—was only diagnosed with an eating disorder years after her surgical procedure due to a myriad of medical complications as a result of malnourishment. While she existed in a fat body, she struggled with atypical anorexia—her care was complex and required a team of interdisciplinary providers to get her on a path to recovery.

Not everyone in a fat body has an eating disorder, not everyone in a thin body has an eating disorder, and not everyone in a “normal” sized body has an eating disorder. But you can have an eating disorder in any one of these bodies. If you belong to a marginalized community, chances are you will not even be assessed for symptoms of an eating disorder.

As a psychiatrist with subspeciality training in both child and adolescent psychiatry and eating disorders, we know that the best predictor of recovery is early intervention and treatment—weight restoration for those who require it and cessation of the binge/purge cycle when present. Most importantly, individuals must learn (sometimes for the first time) how to appropriately nourish their bodies. Initially it is with rigid meal and snack schedules, but over time, an intuitive eating approach is possible for most, once return of hunger and satiety cues occur. The longer someone struggles with any eating disorder, the harder it is to recover, as the more entrenched the cognitive distortions, rigid rules, and behaviors become. However, treatment and recovery are possible no matter where the individual is along the course of the illness.

Because eating disorders thrive in secrecy, those suffering often do not seek care. It is imperative that we, as clinicians, screen for and provide access to treatment that is culturally competent and informed to those in need. Most physicians receive little to no training in eating disorder identification, let alone treatment provision. We must invest in the education of our workforce. Although there are a variety of programs out there for eating disorders, most are private, most accept only private insurance (if they accept insurance at all), and many do not accept patients with significant cooccurring psychiatric illness. This must change—because if we increase screening and detection of eating disorders among minority and marginalized populations, we must have evidence-based, high-quality care to refer them to for treatment and recovery.

If you or someone you know is struggling with an eating disorder, know that treatment is available, recovery is possible, and hope for a better tomorrow exists.

is an instructor in the Department of Psychiatry at Harvard Medical School and an attending physician in child and adolescent and general adult psychiatry at McLean Hospital. She specializes it the care of individuals with eating disorders.

1. Marques L, Alegria M, Becker AE, et al. 

Comparative prevalence, correlates of impairment, and service utilization for eating disorders across U.S. ethnic groups: implications for reducing ethnic disparities in health care access for eating disorders.

2. Parker LL, Harriger JA. Eating disorders and disordered eating behaviors in the LGBT population: a review of the literature. 

4. Swanson SA, Crow SJ, Le Grange D, et al. 

Prevalence and correlates of eating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement.

5. Gordon KH, Brattole MM, Wingate LR, Joiner TE Jr. 

The impact of client race on clinician detection of eating disorders.

6. Becker AE, Franko DL, Speck A, Herzog DB. 

Ethnicity and differential access to care for eating disorder symptoms.

What kind of person comes to mind when you think of eating disorders? Here’s why you might be wrong. 

Eating Disorders in Minority and Marginalized Populations 

A recent study sought to understand the relationship between dietary patterns of children and their 

Investigators examined 2 different age groups of children from Spain: 259 preschoolers aged 3 to 6 years old (57 with ADHD and 202 controls) and 475 elementary-school-age children, aged 10 to 12 years old (213 with ADHD and 262 controls). ADHD was assessed in accordance with the DSM-5. Eating data were collected using a food consumption frequency questionnaire. Three types of eating patterns were identified: Western-like, sweet, and healthy.

Western pattern consists of eggs, processed meat, seafood, savory cereals, potatoes, legumes, sodas, and cooked vegetables. Sweet pattern consists of dairy desserts, sweet cereals, preserved fruit, and sweets. 

 consists of nuts, fish (white and oily), raw vegetables, fresh fruit, and olive oil.

The children and adolescents with ADHD were negatively associated with the healthy pattern (p < 0.001) and positively associated with the Western-like diet (p = 0.004). Furthermore, children with inattentive presentation showed lower adherence (12.2%) to a healthy pattern than that of the control group (39.9%) (p < 0.001). The control group had the highest adherence to the Healthy pattern. However, the two groups had a similar adherence to the sweet dietary pattern.

Previous research explored the association between 

 and the Mediterranean diet—a dietary pattern that includes fiber-rich food such as fruits and vegetables, healthy fatty acids, proteins, and more.

 According to 2 studies, there was less healthy eating and lower adherence to the Mediterranean diet in children and adolescents with ADHD than that in controls.

“We hypothesize that children with ADHD have a low-quality diet with a lower intake of fruits and vegetables than that of their peers without the disorder, and that this shows up specifically in children with combined or hyperactive–impulsive (H–I) ADHD presentations. Moreover, we hypothesize that food consumption generally differs from the established recommendations by dietary guidelines,” wrote the authors.

The authors concluded that there is an association between ADHD and dietary habits, and children with inattentive presentation may be at increased risk of unhealthy eating habits.

1. Rojo-Marticella M, Arija V, Alda JÁ, et al. 

Do children with attention-deficit/hyperactivity disorder follow a different dietary pattern than that of their control peers?

2. Rios-Hernandez A, Alda JA, Farran-Codina A, et al. 

The Mediterranean diet and ADHD in children and adolescents.

3. San Mauro Martín I, Blumenfeld Olivares JA, Garicano Vilar E, et al. 

Nutritional and environmental factors in attention-deficit hyperactivity disorder (ADHD): a cross-sectional study.

A recent study found a negative association between children with ADHD and health eating patterns. 

The Relationship Between Unhealthy Eating and ADHD in Children 

A study identified a key neural mechanism that may directly contribute to binge eating in patients with bulimia nervosa (BN).

In the study, investigators examined brain activation in individuals with eating disorders during these individuals’ efforts to control their eating behavior—making this study the first of its kind.

 They measured activation in 23 women with BN compared to 23 healthy controls using functional near-infrared spectroscopy (fNIRS) during both a standard go/no-go task requiring inhibition of button-pressing responses and a novel go/no-go task requiring inhibition of eating responses. Results showed that the participants with BN made more commission errors during both tasks,

 and that deficient activation of the medial and lateral prefrontal cortices—the brain regions that play a role in the control of behaviors, emotions, and cravings

—was identified in the participants with BN compared with healthy controls. BN subgroups who felt most strongly that they were binge eating during the task (

 = 12) and those with the most severe and most frequent “loss of control” eating (

 = 12) showed an abnormal reduction in bilateral ventromedial prefrontal cortex (vmPFC) and right ventrolateral prefrontal cortex (vIPFC) activation associated with eating response inhibition.

“Our patients describe feeling like they just can’t stop themselves from taking that next bite or sip during binge-eating episodes, but we didn’t understand the neural mechanisms that might underlie that experience,” saidLaura Berner, PhD, assistant professor of psychiatry at Icahn Mount Sinai; principal investigator for the Mount Sinai Center for Computational Psychiatry and the Mount Sinai Center of Excellence in Eating and Weight Disorders; and lead investigator on the study, in a press release. “For the first time, this method has allowed us to measure what is happening in the brains of people with bulimia nervosa when they are trying to inhibit their eating responses, but cannot.”

Fewer than half of adults with BN recover after first-line treatment interventions. The development of more effective treatments has been hindered because the neural bases of the symptoms of BN are still not well understood.

 “Our findings suggest that eating-specific impairments in inhibitory control-related activation may serve as a new target for treatment,” Berner said in a press release. “In fact, we just learned that we received funding from the National Eating Disorders Association to test this idea. We will be using fNIRS-based neurofeedback to train women with bulimia nervosa to increase their own prefrontal cortex activation while eating, and we’ll test how that training impacts symptoms.”

Diminished activation of specific prefrontal brain region may directly contribute to binge eating in bulimia nervosa, new study reveals

. News release. February 28, 2022. Accessed February 28, 2022.

Altered prefrontal activation during the inhibition of eating responses in women with bulimia nervosa

Findings show relationship between binge eating and brain activation.

Study Connects Key Neural Mechanism to Bulimia Nervosa

Researchers found a moderate prevalence of 

 (ICD) and behavioral addiction (BA) comorbidity in individuals with 

 (EDs) in a first-of-its-kind meta-analysis.

Because the prevalence of this comorbidity has never been systematically examined, Daniel J. Devoe, MSc PhD, and colleagues performed a series of random-effects meta-analyses of peer-reviewed literature reporting prevalence of ICDs or BAs in individuals with EDs. The investigators included 35 studies with a total of 9646 individuals who had an ED and analyzed the prevalence of different kinds of behavioral addictions among these individuals. The mean age of participants was 25.5 years (range 16.7 to 43.9), and 97.7% were female.

Results showed that stealing/shoplifting behaviors were the most common form of behavioral addictions in individuals with EDs, with a prevalence of 30%. Devoe et al also noted prevalence of pathological/compulsive buying at 19%, kleptomania at 18%, and pathological internet use at 12%. Intermittent explosive disorder, trichotillomania, and gambling had prevalence rates of 5%, 3%, and 2%, respectively.

Devoe and colleagues identified that ICDs are more closely associated with bulimia nervosa (BN) and binge-purge subtype (AN-BP) than other ED diagnoses and behaviors.This finding supported previous research indicating that individuals with binge-purge subtypes are more likely to struggle with ICDs, partly due to impulse control difficulties and greater emotion regulation. The researchers also noted that certain personality traits (eg, perfectionism, impulsivity), psychiatric comorbidity, age of onset (eg, early age of onset may worsen prognoses), and concurrent substance use disorders may also play a role in deteriorating ED prognoses. They also suggested that future research explore common underlying pathomechanisms.

“Although causal inferences cannot be drawn, the numbers strongly suggest that clinical screening/monitoring of ICDs/BAs should be part of the clinical routine in cohorts with EDs,” Devoe and colleagues concluded.

1. Devoe DJ, Anderson A, Bahji A, et al. 

The prevalence of impulse control disorders and behavioral addictions in eating disorders: a systematic review and meta-analysis

Study also identifies prevalence of specific behavioral addictions in these individuals.

Research Explores Comorbidities in Patients With Eating Disorders

Anorexia nervosa (AN) is a severe psychiatric disorder characterized by restricted eating, significant weight loss, and a profound fear of weight gain. AN and the related disorder, bulimia nervosa, have a lifetime prevalence of 1% to 2% of the population.

 Weight loss in AN results in serious medical consequences and higher levels of care are often necessary to restore weight. AN has the highest risk of mortality of any nonsubstance-use psychiatric disorder and, too often, a poor prognosis.

 Reluctance to recover is sustained by ego-syntonic symptoms that reinforce the illness.

 Only 13% to 50% of patients are considered recovered 1 to 2 years posttreatment, and a sizeable subset (20% to 30%) go on to develop a chronic and unremitting course of AN.

Limited effectiveness of both pharmacological and psychological treatments contributes to this chronicity. Family-based therapy, which works in alliance with parents to maintain eating and restore weight, has had some success in adolescent patients, but not all younger patients achieve adequate benefit. For older patients with AN, evidence-based therapies remain underdeveloped.

Historically, AN has been considered a consequence of psychosocial factors.

 However, considerable recent evidence supports powerful genetic and neurobiological contributions to AN behavior.

 Many affected individuals have an anxious, obsessive, inflexible, and perfectionist temperament that presents in childhood before the onset of AN, becomes exaggerated during illness, and persists in a mild-to-moderate form after recovery. Comorbid depression is common, as is denial of illness and lack of motivation to change.

Recent studies have shed new light on underlying mechanisms driving such AN symptoms.

 For example, when people are hungry, activation of brain circuits normally makes them feel irritable and uncomfortable and makes food more rewarding and motivating. These neural processes appear to be miscoded in AN and sensitized with weight loss.

 Instead, when these individuals become hungry and are presented with food, they experience brain circuit activity associated with considerable anxiety; further, dopamine-related brain mechanisms that motivate and initiate eating fail to activate. Such findings open the door to identifying new targets and new pharmacological approaches in AN.

It is important to note that there are no US Food and Drug Administration (FDA)–approved medications to treat AN. Nonetheless, given the risk of significant physical and psychological consequences of this disorder, off-label prescribing of some agents has become widespread.

For patients with AN who show signs of treatment resistance, the most common medication intervention is atypical antipsychotics. Although promising case reports, open trials, and chart reviews began appearing in the late 1990s, the controlled-trial literature on atypical antipsychotics in AN remains disturbingly limited, which is a testament to the notorious difficulties in recruiting and retaining patients with AN in medication trials. To date, there have been 8 randomized, placebo-controlled trials (RCTs) involving placebo groups. Only 1 of these involved more than 40 patients, and the total number of randomized patients in all trials was less than 350.

Olanzapine is by far the most studied medication for AN, with 5 trials taking place between 2007 and 2019. All but 1 were considered positive, although the degree of benefit typically was small. Two trials involving use of quetiapine had mixed results, and 1 trial with risperidone was negative.

 In the closest thing to a landmark medication study in AN, Attia et al reported results of a relatively large, multisite RCT of olanzapine in adult outpatients in 2019.

 Five sites in North America randomized 152 patients to olanzapine or placebo during a 6-year recruitment period. The 16-week trial used a target olanzapine dose of 10 mg/d (mean, 7.77 mg/d), and investigators found a significant increase in weight for the olanzapine group versus placebo. However, the difference in weight gain (ie, 1 lb of body weight/month for a woman of average height) was modest between the groups; patients using olanzapine gained an average of approximately 1.5 lb of body weight/month. Weight restoration is the primary outcome in any AN trial, but use of a medication hopefully also will impact the powerful thought processes and psychiatric symptoms that drive the illness. Importantly, the authors reported that use of olanzapine showed “no significant benefit for psychological symptoms.”

Despite these limitations, expert articles and guidelines most likely recommend olanzapine as the antipsychotic of choice to treat AN, because so few RCTs have involved use of other medications. In our experience, a few types of patients may particularly benefit from olanzapine. For individuals who desire some degree of weight restoration but are struggling due to lack of appetite or drive to eat, olanzapine may provide improvement. In addition, patients with very high anxiety presenting more as fear than cognitive rigidity may benefit from the sedative-like properties of olanzapine.

However, there are substantial roadblocks to successful use of olanzapine for AN. The quality that led to early interest in and dominant study of olanzapine—its well-known propensity to cause weight gain—makes it unacceptable to the vast majority of patients with AN. At best, many of these individuals are ambivalent about weight gain, and even those who have accepted it as a necessary aspect of recovery frequently fear loss of control over the process. It is critical to understand that improvement in body image for AN patients can significantly lag weight restoration. If a medication adds weight but has little impact on thought process, the patient may experience an intolerable emotional state that greatly heightens the risks of nonadherence and resumption of weight loss.

With 14 atypical antipsychotics available for use in the United States, it is astonishing that so few have been studied in RCTs of AN. Given the highly complex and variable receptor-binding properties of this class, leading to clinically relevant heterogeneity—for example, some atypical antipsychotics are known to treat depression better than others—it is premature to conclude that atypical antipsychotics have only minimal benefit for AN based on results reported with use of 3 of the earlier medications. Lack of RCTs with newer, relatively weight-neutral antipsychotics, especially those having a somewhat different mechanism of action (eg, aripiprazole), may be a serious oversight.

Over the past decade, and with the 2019 olanzapine trial notwithstanding, nearly all additions to the literature on the use of atypical antipsychotics in patients with AN have involved aripiprazole. Five peer-reviewed articles from 4 different sites in 3 countries have described very interesting findings from case series and retrospective chart reviews.

 These reports often show benefit for weight gain, but most notably, they have included remarkably similar descriptions of an impact on thought processes related to AN, particularly the loosening of rigid and entrenched rules and distortions. Observations have included reduced eating-specific anxiety and distress; less rigid food choices; diminished obsessional thoughts about food, exercise, weight, and body image; and fewer eating disorder (ED) rituals. Additionally, many patients reported reduced symptoms of depression and non-ED–related anxiety, which will be discussed in the next section. Therefore, regardless of any direct impact on weight, aripiprazole may indirectly enhance weight restoration by improving cognition and thereby promoting a better response to psychological and dietary treatments. RCTs are needed to further investigate these findings.

What may account for this possible difference between olanzapine and aripiprazole in AN? Olanzapine—as well as most other current atypical antipsychotics, including quetiapine and risperidone—is a 5-HT2

 antagonist. Aripiprazole, in contrast, is a D

 partial agonist, meaning it acts differently at dopamine and serotonin receptors. Theoretical arguments have addressed how use of aripiprazole at lower doses (typically, 1-5 mg/d, with occasional titration up to 10 mg/d) may facilitate learning and behavior change in individuals with AN.

For example, basic research has indicated that dopamine receptor stimulation may be beneficial in suppressing previous fears after extinction training. Moreover, neurobiological research suggests that AN is associated with heightened responsiveness in brain reward circuits, which may be due to a hypersensitive dopamine system. Aripiprazole may downregulate D

 receptor activity, which may improve brain function, reduce anxiety, and aid in the psychotherapeutic process.

Additionally, almost all patients described in this research on aripiprazole use were being treated concurrently with antidepressants. In contrast, no RCT has formally studied atypical antipsychotic augmentation of antidepressants in AN. Although some RCTs allowed patients already on antidepressants to continue them, use was not systematic or evaluated, and the overall numbers were too small to yield meaningful results. We believe that, particularly for medications such as aripiprazole with known significant effects as augmenters, combination treatment may be 1 key to showing a more robust response in controlled trials. On a practical note, adherence also has improved with use of aripiprazole, because it often is better tolerated. Still, some patients encounter akathisia, which we have been able to minimize by initiating therapy with very low doses (eg, as low as 0.5 mg/d in some patients).

AN is associated with high levels of comorbid conditions. More than 40% of individuals with AN have a lifetime comorbid anxiety or mood disorder, over 30% have an impulse control disorder, and about 27% have a substance use disorder.

 Recent data showed that individuals with AN had a 25% risk of receiving any noneating disorder diagnosis during the first 2 years of longitudinal follow-up and a 55% risk of developing comorbid conditions 2 decades after inclusion.

 Comorbid conditions have been associated with greater illness severity and mortality.

Research on eating disorders traditionally has not focused on comorbidities, but new data highlight the need for treatment of those conditions. Whether eating disorder outcomes will be affected by treatment of comorbid psychiatric illnesses is uncertain, but improving quality of life and reducing suicide rates are similarly important goals.

Few medications specific to AN have been approved by the FDA, yet affected patients frequently receive prescriptions for psychotropics.

 However, studies on pharmacological interventions in AN commonly have not been designed to discern whether individuals taking these medications had more severe illness or higher comorbidity than did others. Because depression and anxiety predict more negative treatment outcome in AN, and comorbid psychiatric disorders are associated with higher mortality among this patient population, use of medication to target these conditions is supported.

 Research may have to adapt and focus more on outcome measures that go beyond weight gain; these may include the study of quality of life, mood, and anxiety measures in relation to use of medical interventions. These measures are crucial in preventing weight loss and relapse after significant resources that involve a high level of care have been used for nutritional rehabilitation.

A recent patient with severe AN in our program also had severe, comorbid obsessive-compulsive disorder (OCD). She had many magical thinking–related obsessions that substantially limited her will to live and contributed to overwhelming major depressive disorder with suicidality. The patient was treated with olanzapine to reduce distress and had been on various antidepressant and antianxiety medications, but she never received an adequately dosed trial of a selective serotonin reuptake inhibitor to treat OCD. During weight restoration, we initiated sertraline, which was titrated to 200 mg/d. After 4 months of treatment, the patient experienced significant relief from symptoms of OCD and could start participating in social activities. AN was still a significant struggle, but the patient experienced improvement in daily life activities and overall functioning.

While olanzapine has shown benefit for AN in RCTs, weight restoration tends to be minor, AN cognitions do not appear to improve significantly, and most patients are unaccepting of a medication known to cause weight gain. RCTs of additional atypical antipsychotics, especially those that have a somewhat different mechanism of action (eg, aripiprazole), used alone and in combination with antidepressants are needed. Research into strategies to better treat psychiatric comorbidities in patients with this disorder may reduce treatment resistance. Finally, early investigations to treat AN and its comorbidities with novel biological treatments (eg, psilocybin, ketamine, cannabinoids, and neuromodulation techniques of repetitive transcranial magnetic stimulation and deep brain stimulation) are ongoing.

 is an associate clinical professor of psychiatry at the University of California, San Diego, and medical director of the UCSD Eating Disorders Treatment and Research Program. 

 is a professor in residence of psychiatry at the University of California, San Diego. 

 is director of medical and clinical services at the USCD Eating Disorders Treatment and Research Program, and clinical professor of psychiatry at the University of California, San Diego. 

 is the founder and executive director of the UCSD Eating Disorders Treatment and Research Program, and professor of psychiatry at the University of California, San Diego.

1. Ward ZJ, Rodriguez P, Wright DR, et al. 

Only 13% to 50% of AN patients are considered recovered 1 to 2 years posttreatment, and 20% to 30% go on to develop a chronic and unremitting course of AN. How can we improve these outcomes?

Eating Disorders

Psychedelics for the Treatment of Binge Eating Disorder in Males

Trust, Patience, and Communication: Treating Bulimia Nervosa When Residential Programs are Unavailable

Eating Disorders in Minority and Marginalized Populations

The Relationship Between Unhealthy Eating and ADHD in Children

Study Connects Key Neural Mechanism to Bulimia Nervosa

Research Explores Comorbidities in Patients With Eating Disorders

Pharmacological Management of Treatment-Resistant Anorexia Nervosa

Pennsylvania Legislators Push to Increase Awareness of Eating Disorders in Children

A Life and Death Measure: Eating Disorder Treatment

Breaking the Skinny Standard: Anorexia on Screen