Biology & Treatments for Compulsive Behaviors & Binge Eating | Dr. Casey Halpern
Dr. Casey Halpern, Chief of Stereotactic and Functional Neurosurgery at UPenn, discusses using deep brain stimulation and non-invasive brain stimulation to treat severe compulsive and movement disorders like binge eating, OCD, and tremor. The conversation highlights how understanding and modulating specific brain circuits can offer novel therapies for debilitating human conditions.
Deep Dive Analysis
18 Topic Outline
Introduction to Deep Brain Stimulation for Disordered Eating
Neurosurgery Specialization and Brain Conceptualization
Deep Brain Stimulation's Unexpected Therapeutic Effects
Obsessive Compulsive Disorder: Definition and Treatments
Brain Areas Involved in OCD, Risk, Reward, and Addiction
Stimulants, Stress, Superstition, and Compulsive Behaviors
Nucleus Accumbens, Reward Circuits, and Eating Disorders
Continuous Versus Episodic Brain Stimulation Approaches
Binge Eating Disorder: Onset and Characteristics
Identifying 'Craving Cells' in the Nucleus Accumbens
Effects of Stimulation: Interrupting Craving and Mood
Anorexia, Obesity, and Compulsions: Treatment Potential
Non-Invasive Brain Stimulation: TMS and Focused Ultrasound
Future of Non-Invasive Brain Stimulation for Psychiatric Illnesses
Pre-Behavioral Compulsive States and Awareness
AI and Machine Learning for Compulsion Prediction
Neurosurgeon's Physical and Mental Discipline
Daily Habits for Well-being and Performance
9 Key Concepts
Deep Brain Stimulation (DBS)
DBS is a neurosurgical procedure where a thin, insulated wire is placed deep into a specific brain region. The actual therapy involves delivering electrical stimulation through the wire's tip, connected to a pacemaker-like pulse generator, effectively acting as an electrical 'medication' to modulate brain circuits.
Obsessive Compulsive Disorder (OCD)
OCD is a spectrum disorder characterized by dysregulated cortical areas (like the prefrontal and orbital frontal cortex) and subcortical basal ganglia (ventral striatum, nucleus accumbens). It manifests as obsessions leading to compulsions, which can be an asset if controlled, but debilitating if uncontrollable, causing severe distress and functional impairment.
Nucleus Accumbens
This brain region is a central hub of the reward circuits, crucial for gating reward-seeking behavior. When its function is perturbed, it can lead to compulsive behaviors, driving individuals to pursue rewards (such as high-fat foods or drugs) despite significant risks or negative consequences.
Loss of Control Eating
This term describes a frequent inability to control food intake, which can occur dozens of times a week. It is distinct from a 'binge,' which has specific criteria involving consuming an 'enormous amount of food in a brief period of time' with a sense of loss of control, and typically happens less frequently.
Two-Hit Hypothesis (Binge Eating)
This model suggests that binge eating disorder develops from a combination of factors. The 'first hit' is a predisposition or vulnerability (genetic or environmental, like exposure to highly palatable, cheap foods), while the 'second hit' involves recurring stressful events that trigger and exacerbate the compulsive eating behavior.
Craving Cells
These are specific neurons within the nucleus accumbens that exhibit distinct electrical signals correlated with a patient's self-reported craving for certain foods. Identifying these cells during surgery allows for precise, real-time targeting with deep brain stimulation to potentially disrupt the craving-to-binge cycle.
Transcranial Magnetic Stimulation (TMS)
TMS is a non-invasive brain stimulation technique that uses magnetic fields to stimulate nerve cells in the brain through the intact skull. It is FDA-approved for conditions like depression, OCD, and nicotine addiction, though its ability to target deep brain structures with high precision is somewhat limited.
MRI-Guided Focused Ultrasound
This is an FDA-approved non-invasive method that uses focused ultrasound waves, guided by MRI, to deliver an ablation (destroy a small amount of tissue) to specific brain regions. Currently used for tremor (essential tremor, Parkinson's), research is exploring its potential for modulating neuronal activity or opening the blood-brain barrier for targeted drug delivery.
Compulsion vs. Impulsivity
Compulsion involves pursuing a reward or urge despite known risks, often seen in OCD or addiction. Impulsivity, while similar, is characterized by acting without waiting for a cue or proper timing, such as a mouse immediately seeking a food reward without waiting for a paired signal.
10 Questions Answered
Neurosurgeons deal with the entire central and peripheral nervous system, performing surgeries like tumor removal, aneurysm clipping, and spine procedures. While many tasks are structural, subspecialties like stereotactic and functional neurosurgery focus on modulating brain function, for instance, using deep brain stimulation.
Yes, stimulating certain brain regions can lead to surprising therapeutic benefits, such as improving psychiatric comorbidities like depression or gambling issues in Parkinson's patients, or even inducing temporary feelings of laughter, by modulating limbic circuits involved in emotion.
OCD is a condition involving dysregulated cortical and subcortical brain areas, leading to obsessions and compulsions. Treatments typically begin with medications like SSRIs and tricyclics, alongside cognitive therapies such as exposure response prevention.
The nucleus accumbens, a key part of the brain's reward circuits, can be 'hijacked' by repeated exposure to strong rewards. This perturbation can lead to a 'loss of control,' where individuals pursue rewards despite significant risks, a common factor in binge eating disorder, addiction, and OCD.
A 'binge' is specifically defined by consuming an 'enormous amount of food in a brief period' with a sense of loss of control. 'Loss of control eating' is a broader term, referring to frequent instances where an individual feels unable to control their intake, even if the amount eaten doesn't meet the full criteria for a binge.
Binge eating disorder often develops via a 'two-hit hypothesis': an initial predisposition or vulnerability (e.g., genetic, or societal exposure to palatable foods) combined with recurring stressful events. Societal stigmas around weight can also exacerbate the problem.
Dr. Halpern suggests anorexia and certain forms of obesity (characterized by compulsive overeating) are more similar than different, both driven by compulsions to either over or under-eat despite risks. The nucleus accumbens and related inhibitory control circuits are implicated in both, with ongoing research exploring similar deep brain stimulation approaches for anorexia.
Transcranial Magnetic Stimulation (TMS) is FDA-approved for depression, OCD, and nicotine addiction, targeting superficial brain areas. MRI-guided focused ultrasound is FDA-approved for tremor (ablative), with research exploring its modulatory use and potential for psychiatric conditions, although defining precise targets remains a challenge.
Yes, enhancing awareness of internal states and recognizing when one is veering towards compulsive behaviors (like cravings or negative moods preceding a binge) is considered a powerful tool. However, for severe, refractory patients, even high awareness may not be sufficient to override the compulsion, necessitating more direct interventions.
Neurosurgeons are often self-selected for a calm demeanor, which is further amplified by rigorous training. Many prioritize high-quality personal time and develop coping mechanisms for stress, including maintaining physical health through exercise and practices like meditation to stay calibrated and focused.
11 Actionable Insights
1. Cultivate Self-Awareness for Behavior Control
Develop self-awareness to detect internal states that precede cravings, binges, or other problematic behaviors. Recognizing these “pre-behavioral states” is a powerful tool to intervene and improve outcomes.
2. Avoid Highly Refined, Palatable Foods
Be cautious of readily available, cheap, highly refined foods high in sugar and fat, as they can negatively alter reward circuits and increase cravings. Our brains are not evolved to manage constant exposure to such palatable foods.
3. Use Exercise and Meditation for Well-being
Incorporate regular exercise (including strength training and cardio) and meditation into your routine to manage stress, improve sleep, and enhance overall well-being. Consistency, even with app-guided meditation, is key.
4. Follow Cardio and Resistance Training Guidelines
Aim for 180-200 minutes of Zone 2 cardio (e.g., jogging, cycling, swimming) per week and approximately six hard sets of resistance training per muscle group per week. Perform these with proper form to maintain muscle, skeletal, and tendon health.
5. Hydrate with Electrolytes Daily
Ensure adequate hydration and electrolyte intake (sodium, magnesium, potassium) daily, as even slight dehydration diminishes cognitive and physical performance. Consider dissolving one packet of an electrolyte mix in 16-32 ounces of water first thing in the morning and during physical exercise.
6. Reduce Stigma Around Eating Disorders
Foster a kinder, more understanding societal view towards individuals with eating disorders and obesity, recognizing the brain’s vulnerability. Reducing stigma can help prevent embarrassment and feelings of giving up, which exacerbate these conditions.
7. Manage Stressors and Vulnerabilities
Recognize that modern society presents stresses and exposures (like stimulants) that human brains may not be evolved to manage, potentially leading to conditions like OCD or anxiety. Be aware of personal vulnerabilities to environmental exposures and stressors.
8. Practice Meditation or NSDR
Engage in meditation or Non-Sleep Deep Rest (NSDR) sessions, even for short durations like 10 minutes, to restore cognitive and physical energy. These practices involve lying still with an active mind.
9. Prioritize High-Quality Time & Efficiency
Cultivate the skill of prioritizing and making time high-quality, even in busy schedules, by cutting to the chase and being efficient. This trait helps manage stress and maintain connections despite demanding work.
10. Incorporate Incidental Movement Daily
Even when time for dedicated exercise is limited, make a conscious effort to incorporate incidental movement, such as taking the stairs instead of elevators, to maintain physical activity. This can become a beneficial habit over time.
11. Exposure Response Prevention for Compulsions
For compulsive behaviors, consider Exposure Response Prevention (a form of cognitive therapy) to habituate to stressors and reduce compulsions. This involves controlled exposure to the stressor to help the brain adapt and function normally.
8 Key Quotes
Deep brain stimulation, the surgery that I do routinely, is a procedure where, yes, there is structure involved, of course. We have to place a very thin wire that's insulated deep into a part of the brain that's involved in Parkinson's disease, for example. But that's actually not the therapy. The therapy is delivering electrical stimulation through the tip of that wire or one of the tips, as there actually are multiple contacts at the bottom of the wire. They're very small. But that's all done out of the operating room.
Casey Halpern
I would say the most impressive and consistent effect we have when we have a patient with tremor who has been tremoring for the past 20 years, if we can deliver stimulation through that electrode in the clinic, we have immediate relief of tremor.
Casey Halpern
If you have an urge for a reward that either puts you or somebody else at risk, it's probably a reward we shouldn't have.
Casey Halpern
I actually think people would understand where I'm coming from across all of these sort of subspecialties of medicine, but I actually think especially with obesity, remember it's a phenotype that's reflective often but not always of a behavior, but if you consider patients that have obesity and they exhibit some sort of compulsion towards food so they overeat despite the risk of it, I think those kinds of patients are more similar to anorexics than they are different.
Casey Halpern
I've always believed that neurosurgeons need to be part of the discussion with these non-invasive approaches. We don't need to do them, but I think we can help make them more precise and to probe non-invasively with purpose rather than this more non-invasive blast effect.
Casey Halpern
I've always thought that if we can improve awareness, we can improve outcomes.
Casey Halpern
We need real therapies for these things, not that these devices that we're discussing are not. I think actually there's lots of promise and we use machine learning in the lab all the time... but I definitely think there's a future for it. I suspect we're scratching the surface on how best to do it.
Casey Halpern
I've also heard us compared to cowboys before, and it's surgically really does require a substantial amount of confidence. And that confidence hopefully comes from years of training and experience.
Casey Halpern
1 Protocols
Deep Brain Stimulation Trial for Loss of Control Eating (Research Protocol)
Casey Halpern- Identify 'craving cells' in the nucleus accumbens during surgery by listening to single neuron electrical activity.
- Provoke food craving in the operating room by showing patients pictures of highly craved foods (e.g., salty or sweet items) while they are awake and fasted.
- Deliver brief electrical stimulation (5-10 seconds) to the identified craving cell region, aiming to temporarily elevate mood and disrupt the craving-to-binge cycle.
- Obtain an intraoperative CAT scan to confirm the precise accuracy of electrode placement (within 0.5 millimeters of error).
- Use connectomics (tractography) to map circuit connections from the nucleus accumbens to the prefrontal cortex and target the intersection of this pathway structurally.
- Post-surgery, in a laboratory setting, provoke binges using a mood provocation technique by a psychiatrist to induce feelings related to the patient's self-described binge episodes.
- Video record and synchronize brain signal recordings with eye-tracking data to understand what is happening immediately before a bite, to detect the craving cell signal and trigger stimulation.