September 26, 2022 • 2hr 11min

Dr. Casey Halpern: Biology & Treatments for Compulsive Behaviors & Binge Eating

Huberman Lab

In this episode, Dr. Andrew Huberman interviews Dr. Casey Halpern, Chief of Stereotactic and Functional Neurosurgery at the University of Pennsylvania. They discuss Dr. Halpern's pioneering work using deep brain stimulation and other neurosurgical techniques to treat compulsive behaviors and movement disorders. The conversation covers the neurobiology of conditions like binge eating disorder and OCD, the promise and challenges of deep brain stimulation, emerging non-invasive brain stimulation methods, and provides fascinating insights into the unique mindset and skills developed by neurosurgeons.

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Key Takeaways

Deep brain stimulation (DBS) is a surgical technique that involves implanting electrodes in specific brain areas to modulate neural activity and treat various neurological and psychiatric conditions
Dr. Halpern's research focuses on using DBS to treat compulsive behaviors like binge eating disorder, obsessive-compulsive disorder (OCD), and movement disorders
The nucleus accumbens is a key brain region involved in reward processing and compulsive behaviors that is often targeted with DBS
Binge eating disorder affects 3-5% of the population and is characterized by episodes of consuming large amounts of food with a sense of loss of control
DBS of the nucleus accumbens shows promise for treating severe cases of binge eating disorder that have not responded to other treatments
Non-invasive brain stimulation techniques like transcranial magnetic stimulation (TMS) are also being explored for treating psychiatric conditions, though they currently lack the precision of DBS
Focused ultrasound is an emerging non-invasive technique that can be used to ablate or modulate specific brain regions
Machine learning and AI may help predict and prevent compulsive episodes in the future by detecting subtle physiological changes
Neurosurgeons develop unique skills like extreme focus, calmness under pressure, and efficient time management due to their rigorous training

Introduction

In this episode, Dr. Andrew Huberman interviews Dr. Casey Halpern, Chief of Stereotactic and Functional Neurosurgery at the University of Pennsylvania. They discuss Dr. Halpern's pioneering work using deep brain stimulation and other neurosurgical techniques to treat compulsive behaviors and movement disorders. The conversation covers the neurobiology of conditions like binge eating disorder and OCD, the promise and challenges of deep brain stimulation, emerging non-invasive brain stimulation methods, and provides fascinating insights into the unique mindset and skills developed by neurosurgeons.

Topics Discussed

Deep Brain Stimulation and Neurosurgery (6:41)

Dr. Halpern explains that deep brain stimulation (DBS) involves implanting thin electrodes into specific brain regions to deliver electrical stimulation and modulate neural activity. Unlike more structural neurosurgeries like tumor removal, DBS aims to alter the functioning of neural circuits.

DBS electrodes are connected to a battery pack/pulse generator implanted under the skin
Stimulation parameters can be adjusted non-invasively after surgery
DBS is used to treat conditions like Parkinson's disease, essential tremor, and OCD
It can produce rapid and dramatic improvements in symptoms like tremor

Obsessive-Compulsive Disorder (OCD) and Brain Circuits (16:50)

Dr. Halpern discusses the neurobiology of OCD and approaches to treating it:

Key brain regions involved in OCD: Orbitofrontal cortex, prefrontal cortex, basal ganglia structures like caudate and putamen
These areas show dysregulated activity in OCD patients compared to healthy controls
First-line treatments: SSRI medications, cognitive behavioral therapy, exposure and response prevention therapy
DBS may be an option for severe, treatment-resistant cases of OCD
DBS for OCD typically targets areas like the nucleus accumbens or anterior limb of internal capsule

"I actually think, especially with obesity...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." - Dr. Casey Halpern

Nucleus Accumbens and Reward Circuits (37:54)

The nucleus accumbens is a key brain region involved in processing reward and driving motivated behaviors:

Part of the brain's reward circuitry
Involved in both adaptive reward-seeking and maladaptive compulsive behaviors
Animal studies show high-fat diet exposure alters nucleus accumbens functioning
Dr. Halpern's lab is studying DBS of nucleus accumbens for binge eating disorder

Binge Eating Disorder and Loss of Control Eating (48:23)

Dr. Halpern explains key features of binge eating disorder:

Most common eating disorder, affecting 3-5% of population
Characterized by episodes of consuming large amounts of food with loss of control
Severe binge eating disorder involves ~1 binge episode per day
Loss of control eating is a key feature that can occur more frequently
Often co-occurs with obesity but they are distinct conditions

Deep Brain Stimulation for Binge Eating (1:00:12)

Dr. Halpern describes his lab's pioneering clinical trial using DBS to treat severe binge eating disorder:

Targeting the nucleus accumbens
Aims to identify "craving cells" that predict binge episodes
Uses responsive stimulation triggered by detected craving signals
Stimulation aims to disrupt the craving-to-binge cycle
Still in early stages with only a few patients treated so far

"We want to deliver a episodic therapy delivered at the right time and only at the right time to try to interrupt the circuit aberration or the problem at hand that is going to lead to that dangerous behavior and to kind of get the patient back on track to what they're doing." - Dr. Casey Halpern

Non-Invasive Brain Stimulation Approaches (1:21:31)

The discussion covers emerging non-invasive brain stimulation techniques:

Transcranial magnetic stimulation (TMS):
- FDA-approved for depression, OCD, and nicotine addiction
- Targets cortical regions like prefrontal cortex
- Limited in ability to precisely target deep brain structures
Focused ultrasound:
- Can non-invasively ablate or modulate specific brain regions
- FDA-approved for essential tremor
- Being explored for psychiatric conditions but targets still unclear

Dr. Halpern emphasizes the need to better understand optimal brain targets through invasive studies before non-invasive approaches can be fully effective for psychiatric conditions.

Machine Learning and AI for Predicting Compulsions (1:45:18)

The potential for using machine learning and AI to predict and prevent compulsive episodes is discussed:

Could integrate data from wearables, voice patterns, etc. to detect subtle changes
May allow early intervention before a person is consciously aware of urges
Dr. Halpern believes this approach has promise but is still in early stages
Emphasizes need for rigorous validation to avoid ineffective consumer devices

Neurosurgeon Training and Mindset (1:56:27)

Dr. Halpern provides insights into the unique skills and mindset developed through neurosurgery training:

Extreme focus and calmness under pressure
Ability to efficiently prioritize and make the most of limited time
Resilience developed through long hours and high-stakes situations
Importance of self-care practices like exercise and meditation

"We tend to have this sort of unflappable personality that perhaps we started with a bit compared to the average person, but the training definitely amplifies it." - Dr. Casey Halpern

Conclusion

This wide-ranging conversation provides fascinating insights into cutting-edge neurosurgical approaches for treating psychiatric and neurological conditions. Dr. Halpern's work using deep brain stimulation for compulsive eating disorders represents an exciting frontier in precision neuroscience. While still in early stages, this research offers hope for new treatment options for severe cases that have not responded to conventional therapies. The discussion also highlights the rapid progress being made in non-invasive brain stimulation techniques, though significant work remains to achieve the precision of invasive approaches. Finally, Dr. Halpern's reflections on neurosurgery training illuminate the intense dedication and unique skills developed by those in this demanding field. Overall, this episode offers an inspiring look at how advanced neurotechnology may transform the treatment of brain disorders in the coming years.