← ADHD Experts Podcast
ADHD Experts Podcast
545- The Surprising Association Between ADHD & Inflammatory Disorders
01:02:08
Join James Kustow, BMBS, MRCPsych, to learn about the emerging research that may explain ADHD’s unexpected associations with inflammatory conditions like allergy and autoimmunity — and a surprisingly strong link with hypermobility syndrome. ADHD...
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This episode is brought to you by Progressive Insurance. Do you ever think about switching insurance companies to see if you could save some cash? Progressive makes it easy to see if you could save when you bundle your home and auto policies. Try it@progressive.com Progressive Casualty Insurance Company and affiliates. Potential savings will vary. Not available in all states welcome to the Attention Deficit Disorder Expert Podcast series by Attitude Magazine.
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Everyone. I'm Carol Fleck and on behalf of the Attitude team, I'm pleased to welcome you to today's ADHD Experts presentation titled the Surprising association between ADHD and Inflammation. Leading Today's presentation is Dr. James Cousteau. Dr. Cousteau is a London based psychiatrist and one of the few adult ADHD specialists in the UK's National Health Service. He's the Medical Director of the Growth Practice, an internationally respected mental health training provider. He's also a trained integrative psychotherapist. Dr. Cousteau is the author of how to Thrive with Adult seven Pillars for Focus, Productivity and Balance. And like many of you, he was diagnosed with ADHD as an adult. If you support the work we're doing here at Attitude to strengthen the ADHD community, we encourage you to visit attitudemag.com subscribe and sign up for Attitude Magazine. Finally, the sponsor of this webinar is Inflow. Living with ADHD and dealing with inflammation related challenges can be overwhelming and exhausting. Inflow gets it developed by leading ADHD experts. Inflow is a science backed self help program and it uses proven strategies to help you tackle behaviors, build healthier routines and regain control of your life. Click the link on screen to take Inflow's free ADHD Traits quiz to get started. Attitude thanks our sponsors for supporting our webinars. Sponsorship has no influence on speaking, speaker selection or webinar content, so without further ado, I'm so pleased to welcome Dr. Cousteau. Thank you so much for joining us today and for leading this discussion.
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Thank you very much and thank you all for joining today. It's very exciting. I just learned that There are over 21,000 people registered for this session, which is pretty high and testament to the fact that this is a topic that is attracting a lot of interest at the moment and we are relatively early on in the journey of making sense of these links that I'm going to start to share with you today. So I'm very pleased to be here and I'm going to hopefully keep your attention for the next 35 to 40 minutes of my presentation, at which point we'll move to a question and answer session by means of a brief introduction. I wanted just to share why or how I became interested in the relationship between inflammation and ADHD. I actually grew up with undiagnosed ADHD. My diagnosis took place at the age of 33. So I managed to get through medical school training and the first part of my psychiatry training without properly appreciating that ADHD continues into adulthood in the majority of cases, and also that I myself had it. I also hadn't appreciated that there is significant and quite interesting overlap with many physical health problems. And as well as growing up with undiagnosed adhd, I also had a range of physical health issues, inflammatory type presentations, allergies that I just assumed was normal. And only later as I started to see and make connections did I realize that it's very much part of a bigger picture of which ADHD is one component. I had a fascinating experience over the last 10 years or so, primarily because about 10 years ago on a lecture tour in the Middle East I got a tick bite and developed Lyme disease. And Lyme disease is not much fun. What it does is it causes quite a bit of dysregulation of the immune system and my immune system over a few years basically became hypersensitive and hyper reactive to everything. My sensitivity went up enormously and through my own experiences I learned a lot about this relationship. The other thing that happened in my life, in my family's life, was that my youngest daughter at the time of COVID so a few years after my Lyme disease diagnosis suddenly developed something called pandas, which is an autoimmune brain condition, but one that presents with mental health symptoms. It presents with obsessive compulsive disorder symptoms and a worsening of her pre existing adhd. Now I never realized that inflammation in the form of autoimmunity in this case was so directly correlated to mental health and neurodevelopmental symptoms. Until this point we would see her OCD and ADHD and mood changes increasing in line with her inflammation and reducing in line with the anti inflammatory treatment that she was getting. And this taught me a lot. This taught me that we probably she's not the only one whose inflammatory status is directly linked to their mental health and neurodevelopmental symptoms. So that was the background and that led me to when you have a child who's unwell and you're unwell, it leads you to deep dive into this area to try to make sense and to try and improve the situation. That's exactly what I did, and I found some fascinating correlations and connections, some of which I'm going to share with you today. So, starting with some of my disclosures, you can see that I do various things within the world of adult adhd. I work in the nhs. I also have a private practice and I'm the Director of education for the main professional organization for ADHD in adults in the UK called ucan. I'm on the Executive Board for ucan. I'd like to state that I'm not speaking on behalf of my NHS team, I'm not speaking on behalf of ucan, I'm speaking on behalf of myself. Just to make that clear. I'm also the author of a new book by Penguin called How to Thrive With Adult adhd, which I'll introduce briefly in a moment. So what are we going to do today? What are we going to cover in this whole half an hour? I have my little measure here to keep me on track with timing. I'm going to just orientate you a little bit to the focus of today's session. My overarching goal is to widen the lens around ADHD in order to bring much more needed focus to the body. Within that, I am planning to explore and introduce to you what we call somatic or physical health overlap or comorbidity with adhd. Over recent years there have been a number of studies showing that there are various physical health problems that occur at higher rates than you would expect, or higher rates than are present in the non ADHD population in those with adhd. And emerging out of this data are various clusters, many of which have an inflammatory basis. I'm going to orientate you to what we currently know. There are many unanswered questions and we're really quite at an early stage in this process. But what I've seen and what I've read and understood and personally experienced is that there's a very strong and not particularly well explored overlap with inflammation and more specifically brain or neuro inflammation. And as a result, I put together what I've termed my 10 point neuro inflammatory hypothesis of ADHD, which is essentially 10 clusters of evidence that tell us that ADHD in many, probably not in all, is strongly inflammatory and is very much linked to the immune system, not just the brain as we currently think. So it seems that much of this infection, inflammation, seems to have links with a connective tissue problem referred to as joint hypermobility. This is when individuals have lax joints, joints that bend more than they should. But the story is much more than simply lax joints and it overlaps strongly with inflammation primarily through something known as mast cell activation disease. I'm going to just introduce you to this condition because not many people are aware of it. The result of all these explorations and connection forming is another model which is called the somatic super syndrome or 3S model. And specifically its neuropsychiatric signature essentially is a cluster of syndromes, a cluster of multi system problems that come together and for different reasons drive brain pathology or brain symptoms, neuro, neurological, psychiatric, to do with mental health. And this model really aims to. And it's not just relevant to adhd. I think it's relevant to many mental health presentations and I'm going to show you how and why. Much of the stuff that I'm going to be talking about are my own hypotheses about how these links are formed. Many of them have evidence supporting them, but it's certainly not in some areas widely accepted mainstream understanding. We are partway through a journey into unpicking these things. It's very exciting area to be in because it radically changes the way that we think about not just ADHD and neurodevelopmental problems, but mental health more broadly, much more as a systemic or full body presentation. So I like to really understand ADHD as an issue or a disorder and I use the word cautiously and very aware that it's going to get the backs up of some people who do not like to think of ADHD as a disorder. And the difference is that I work in psychiatry and, and I work with individuals who have significant amounts of disorder in their lives as a result of their adhd. I think we can see ADHD within a social construct and we can also see it within a medical or clinical construct, obviously coming from the clinical angle, but I do recognize that it's not such a straightforward picture and, and that our environment and the world around us really determines in many ways how much disorder is expressed. So I just want to, sometimes I will refer to it as an issue with regulation, but I don't want to detract from the fact that there's a lot of impairment and struggle linked to this thing we have called adhd. I think that the current diagnostic criteria, the way that we diagnose ADHD using the DSM or the ICD 11 now really gives quite a narrow perspective of this condition. And I remind people that how you diagnose a patient problem is often quite different from how it looks and presents in real life. The real lived experience of ADHD is so much more than the list of symptoms that we see in dsm, which after all, was written originally for children and adapted in DSM 5, the latest version to be more relevant to adults. But ADHD in the real world is far more nuanced and far more complex. So I developed a few years ago a model called the 10 Domains of Dysregulation to really capture this. And what it also does is it broadens the frame and starts to think more about the body and other systems in the body, including, importantly for our discussion, the immune system. Each of the 10 domains has a set of first level features. These are symptoms or features that can result from dysregulation of that domain. And in addition, I introduce a range of second level features which are divided into adverse outcomes and negative aspects of adhd. These are the problems that result if you don't take care of your adhd. And we know that there's a whole raft of really negative and toxic outcomes linked to ADHD that have been very well studied in many different ways, including higher rates of suicide and reduced life expectancy. And to not consider this as a severe condition in many is somewhat missing the point. But there are also, as you will all know, a number of potentially adaptive features linked with adhd. And this model also captures those. The resilience, the intuition, the creativity, the divergent thinking. And the list does go on. So my model hopefully opens up the frame to include a few other things that are not necessarily explored in our current model.
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You will see the 10 domains listed there and the first four of which you will recognize as they form. First three, at least form the bulk of the diagnostic criteria. That's the attentional activity and impulse related issues. The fourth domain, emotion emotional dysregulation, is widely accepted as being a core feature of adhd, despite the fact it's not included in the diagnostic criteria. However, domains 5 to 10 are less often explored and discussed, including the reward system, the sensory system and sensory processing issues. How the ADHD brain deals with time issues around time appraisal, the biological disruption of the sleep, wake cycle or circadian rhythm. And again, importantly for Today, the immune system, the immune function and inflammatory status. Clear evidence of dysregulation in ways that I'm going to explain in just a moment. And finally, dysregulation in the way that we expend and use energy, often in a boom and bust type of pattern, and how our arousal system works. Arousal is central to understanding many of the problems in ADHD. So this is the 10 domains of dysregulation model. I introduce it formally in my book and it seems to be attracting lots of interest. I'm going to focus today on domain 9 for the most part and try and build a picture for you. When I started to look into this area and really understand the overlaps between ADHD and various aspects of inflammation, I felt it was appropriate to synthesize this into a model. The neuroinflammatory hypothesis of ADHD is actually what I refer to it as. And I'm just going to orientate you to to some of these connections so that you understand how we know that ADHD and inflammation are overlapped. Well, first of all, and probably most importantly, is that ADHD coexists with a whole range of inflammatory conditions, including allergies and autoimmune disorders. There are many others and I'm going to talk about them in just a moment. Numerous studies have shown that there are inflammatory markers, which basically means tests, usually blood tests, that mark levels of inflammation. There are many of them and many, many are raised in individuals with adhd. At a group level. There are issues linked to inflammation, including premature birth, low birth weight, neonatal infections that have been shown to increase the risk of ADHD and moving the focus from the fetus or the neonate to the mother. Maternal inflammation, whether it's through allergy, autoimmunity or dysfunction of the metabolic system, including obesity, has been shown to increase the risk of ADHD via inflammation passing through to the unborn child. We know that gut dysbiosis or imbalance of the gut microbiota or microbiome which is associated with inflammation, links with ADHD and other neuropsychiatric presentations. There's some evidence, interestingly, that methylphenidate, one of the main stimulants we use to treat adhd, may actually reduce inflammation in certain cases. However, these findings are contradicted in some other animal studies. So really this is not a clear cut finding yet. There are other animal studies that suggest links between ADHD related traits and inflammation. We know from a few different studies that that food allergies and intolerances which contribute to inflammation in the gut. And inflammation across the whole system may potentially drive ADHD symptoms, worsen ADHD symptoms, with some findings actually that again contradict. So again, we've got lots more to learn in this area. There are genetic studies showing that certain genes that are linked to inflammation occur in higher rates with those with adhd. And loads of indirect evidence, things like vitamin D, which is anti inflammatory, being lower in adhd, and then iron deficiency and low ferritin being more common in adhd, again with serving as markers really for inflammation. We know that certain children with ADHD have lower levels of fatty acids, which is the link with omega 3, and the supplementation with omega 3 has been shown to be effective in certain individuals, probably those with lower levels. So there's loads of evidence to tell us that inflammation is linked to adhd. But the real challenge is understanding the mechanism by which that inflammation is happening. And hopefully I'm going to share some theories really that need further study. I just want to mention that each of these 10 items is backed up by lots of research. You can see just the first two, a number of different studies going back to 2000, probably 2005 or even earlier, showing these findings over and over again. So what about the conditions, the inflammatory conditions that have been shown to be occurring at higher levels in those with ADHD than you would expect in individuals without adhd? Well, right at the top of the list is allergy and what we refer to as ATP atop is asthma and eczema, et cetera. So whether it's hay fever or asthma or eczema or dermatitis, we see higher levels, significantly higher levels occurring in individuals with adhd. The same is the case for autoimmune presentations and disorders, psoriasis being one of them. Autoimmune thyroid diseases is particularly common and diabetes, which is an autoimmune presentation type 1 diabetes. And the condition that I referred to at the beginning of the talk, which is pandas, which is basically an autoimmune brain condition where the system mistakenly attacks a part of the brain called the basal ganglia, causing inflammation in that area. And the symptoms that I mentioned earlier, many infections, including Covid, have been linked to to adhd. Most of the studies have been done in children. And links with gastrointestinal, respiratory and urinary tract infections are coming up commonly for different reasons. Sexually transmitted infections associated with adhd, but that's less likely to be through an immune process. But it's possible as well. Immune deficiency has some links. Studies by researcher Merzon and his team and the list goes on. Metabolic issues, including obesity and metabolic syndrome and type 2 diabetes have been shown to be linked. Various neurological and sleep related issues, including epilepsy, Sleep disordered breathing, which is otherwise known as sleep apnea and migraine, have strong links with adhd. And then there are this cluster of connective tissue pain and fatigue disorders, whether it's fibromyalgia, chronic fatigue syndrome, chronic pain, other forms of chronic pain and hypermobility, people who have lax joints, which I'm going to expand upon shortly. We've talked about the raised inflammatory markers. Here's some of the markers that have been shown to be increased in those with ADHD as well as autoantibodies. So these are the things that drive autoimmunity and they attack various parts of the brain and in some cases the body. There are some, again, some contrasting or contradictory findings. There was a study showing no association between an inflammatory marker called CRP and ADHD risk, but on the whole we found that higher inflammatory load increases the risk and severity of adhd. My question that I want to pose to you is if we broaden out this frame and we start looking more at these patterns and these connections, could it be that we are looking at a much bigger and broader syndrome with ADHD as just one expression? It's controversial, I know, especially as there's quite a lot of evidence showing that ADHD definitely is a brain related problem. But I'm arguing that it's also a body related problem. And I'm going to show you some very exciting ideas to explain that. I'm just going to read this extract from a poem that I wrote called Systemic Toxicity. You'll be able to find it online if you're interested. But I think this little aspect of it, it's quite a long poem, but this little part of it I think really captures what I'm trying to communicate. So what can one do for when faced with this mess, I know not the answers, I really must confess, but let's take a step back. Notice the patterns, ask the right questions and then make connections. A systems perspective is what is suggested and what might you discover? A cluster of syndromes that journey together, so common, yet hidden from all but a few who often themselves are suffering too. A cluster with lax joints right at its core. But with it there often comes a whole lot more. A cluster so toxic, inflaming the brain and draining the mind of the joy and the drive that keeps us alive. So taking the focus slightly away from inflammation, specifically, these are the clusters of physical health Problems that occur in adhd actually, ADHD across the board, but many of the studies have been in adults. So there's the immune and the atopic conditions which we talked about. There's cardiovascular problems and some of these are linked to high blood pressure, but others are linked to what we refer to as autonomic nerves, autonomic issues. So issues with the autonomic nervous system, where often the problem relates to not enough blood getting to the brain, the neurological issues, sleep problems, epilepsy, migraine and possibly neurodegenerative problems, although the research is really early there. And then there's the conditions linked to living a lifestyle, the lifestyle aspects of ADHD that might not be so healthy. So whether it's drinking, smoking, drug use, sexual stuff, that clearly that's going to drive some illness, you might have medication related complications. Although I must say that the medications we use in ADHD in general are very effective and seemingly very safe as well. And then hypermobility, and this is an odd one. Why hypermobility and what is hypermobility? I just want to make the point that there are certain physical health problems that are explainable, really. If you don't sleep much and you don't eat healthily and you use substances and you take risks, you're going to have various physical health problems and of course things linked to the medication. But there are some conditions that are less easily explainable that need a different model to explain them. And these include, as I've mentioned, asthma, allergic rhinitis and other allergies, a whole range of autoimmune conditions. We've touched on sleep disordered breathing, abnormalities of the eye, migraine and hypermobility. And just to make the point, if you have a great study by a researcher from the UK called Jessica Eccles and her team showed that approximately 50% of individuals with ADHD are hypermobile. And if you look the other way around, the relationship is really strong. My question when I started seeing so much hypermobility in my patients many years ago now is why? How, what? So I'm going to focus briefly on hypermobility for a moment. And this is a typical patient with ADHD. This particular lady who was almost 30 years old had some features suggestive of autism. She was hypermobile and had a whole host of joint related problems and pain related issues which are listed up there. She also complained of getting dizzy and lightheaded and standing and getting fast heart rate when she stood up from sitting. She had some gastrointestinal issues and some allergies as well. So Let me just orientate you. Hypermobility is a result of the connective tissue issue or abnormality. Connective tissue is a tissue which holds the body together. And one of the main proteins is collagen. And when collagen is defective in some way, individuals will have lax joints, but they'll also have lax tissues across the whole body. It may not be a problem. Asymptomatic joint hypermobility. Not everyone with hypermobility has issues or illness or pathology. But those that do fit into these two categories, Ehlers Danlos syndrome and hypermobility spectrum disorder. And you can see it's a affecting every part of the body, all the systems of the body, because all the systems of the body are held together by connective tissue. And this is my other daughter, Mia, who is very hypermobile. And you can see she can do various maneuvers with her fingers and her arms. She can touch the floor flat with her hands. And this is her bruise. She had a bruise, and she showed me the bruise. And you could see the blood is literally tracking through the tissues. And because they're lax, they're open, they're more. So you can see that every aspect of the system, and here's all the places that there's collagen in the body. It's not just about joints. It's not just about ligaments and tendons. And, you know, joint laxity is common, 10 to 20, maybe even 30%. But when it occurs with other problems, as I said, it becomes a disorder. Now, what we've seen or we understand, is that these people with symptomatic hypermobility syndromes cluster together with those with something called dysautonomia. This is disorder of the autonomic nervous system and something called mast cell activation disease, which is essentially hyperreactivity of the immune system, and all of these things in different ways. And this is not the time to dive into the detail here. Drive neuropsychiatric symptoms in a range of them, and I'm going to show you some of them. These problems also are strongly associated with gastrointestinal problems and with autoimmunity. So we're seeing a picture building here where connective tissue, immune dysfunction, autonomic dysfunction, gastrointestinal problems are clustering together in this network. And I developed a model that pulls all this together. And I'm not expecting you to look at this slide and understand it all now, but what I want to show you is that this triad in the middle that I introduced you to, along with the gastrointestinal Autoimmunity are, for different reasons, in different ways, driving mental health and neurodevelopmental symptoms, not simply just because of dopamine and noradrenaline levels in the brain, but because the brain's not getting enough blood and oxygen and that the inflammation in the body is going to the brain. And you can see down the right column here, all of the different mental health type issues that are linked to this cluster. And the question really is how much of mental illness and how much of neurodevelopmental problems are being driven by body based issues such as brain perfusion and neuroinflammation issues. And draw your attention here, really to this category here, which is the attentional and memory problems often lost in the term brain fog. How does chronic brain fog differ from adhd and how much overlap are we talking about? These are the mechanisms that I mentioned, which I will elaborate on briefly. Dysautonomia, the autonomic nervous system not functioning properly and neuroinflammation. You can see someone standing up and the blood's just not reaching the brain in the same way as it is when they're sitting now. So this is the autonomic nervous system, the sympathetic and parasympathetic, and they are in opposition. One is the stress response and the other is the relaxation response. And the system is both one of the main threat response systems of the body, but it's also the way that blood is moved around the body, including to the brain. And when you have dysautonoma, often you'll experience symptoms on standing, standing upright, not getting enough blood to the brain and then getting symptoms. And one of the groups of disorders, one of the conditions in dysautonomia is pots, but there are many others. And like adhd, dysautonomia can start in childhood, it can continue through life, and it can cause many of the symptoms that we understand to be adhd. Let's move the focus to inflammation, which is the main topic of today. This is a mast cell. It's a form of blood cell, white blood cell, but one that doesn't generally reside in the bloodstream, but in the tissues of the body and specifically at the environmental interfaces of the body where the body meets rest of the world. And these are very important cells. They are often referred to as the first responders. They have loads of receptors on their surface that register various different threats from the outside world and some from the inside of the system and release a whole concoction of different chemicals into the tissues. Or into the bloodstream that are there to try and deal with the threat. You can see where these red dots are here. Eyes, ears, nose, throat, the respiratory tract, the gastrointestinal tract, the genitourinary tract, the skin. These are all the places where threats reside. Whether it's infection or allergy or injury or vibration or pressure changes, these cells are phenomenally effective at picking up any threats. And the problem is, in some people, they are jumpy. They respond too quickly, too easily to potential external threats. And if you're interested to see in real time what a mast cell looks like when it's activated, it goes from looking like a normal closed cell to literally breaking open and releasing all these chemicals into tissues. I can't show the video on this webinar, but you can go to YouTube and type in this text here on the right side and you'll see something quite phenomenal. When people have mast cells that are misbehaving, it's referred to as mast cell activation disease. And until relatively recently, we only really thought about some rare conditions where the mast cells act much like a cancer, they proliferate excessively. Where, however, there's another group of conditions where the mast cells don't proliferate, they just release excessive amounts of chemicals. And this is referred to as mast cell activation syndrome. This is the mast cells. And you can see when mast cells release these chemicals, whether it's histamine, which is the best known one, or cytokines or interleukins, or a whole host of other things, they have impacts on every system of the body through this widespread inflammation. And many of the things that we conditions that we present are going to be doing so through this mechanism. We know about mast cells. Mast cells are what release chemicals in allergies, what make your lungs tighten up in asthma. Histamine causes many conditions that we see all the time, but there may well be more, and particularly there may well be neuropsychiatric presentations. In fact, there are, and I'm going to show you how. So, mast cell activation syndrome, still controversial because it's only described about 15 years ago. It can be secondary to other problems like allergies or infections or. Or it can be a direct problem with the mast cell through genetics. The key thing is that inappropriate activation results in lots of chemicals released and wide ranging symptoms, allergic type, inflammatory type symptoms. And normally the story is people have maybe some allergies or ATP or some odd pockets of inflammatory issues during childhood, and then something comes along, flares up the situation and causes a whole host of symptoms causes the mast cells to really upregulate and start and not come back down to baseline often. Importantly, this is associated with prominent neuropsychiatric symptoms, many of which overlap with adhd. What triggers mast cells to release chemicals? Well, infections or fevers, including Lyme disease or glandular fever. This is the story where people get glandular fever or Lyme disease or Covid and they get long glandular fever, long Lyme disease or long Covid. Much of long Covid is explained by mast cell activation, but equally physical stimuli like pressure or friction or even exercise, stress or trauma. You know, mast cells have receptors on their surface for stress hormones. So this is the link, I think with between trauma and physical health problems. Stress drives inflammation, allergens, drugs, toxins, certain foods and alcohol, where usually ones that contain lots of histamine. Changes to the environment, particularly issues with mold and possibly with electromagnetic radiation, although again a controversial area and importantly particularly for women, the changes to the hormones, whether it's changes over a month or changes around the menopausal period where hormonal shifts take place, causing mast cell activation, particularly estrogen. There are receptors for estrogen on mast cells. Now this has been studied for some time. It takes a long time for this information to permeate through. But there's a number of neurological conditions on the first line that have been linked with mast cell activation and various mental health and neurodevelopmental conditions. And in your own time you can look up the detail here. I just want to illustrate that this is not coming out of the blue. And again, many findings here. I've listed seven big ones that link mast cells with neuropsychiatric presentations. And again, I'm putting this here to show you that there is lots of evidence to show these connections. It's just we haven't been thinking about them in ADHD until very recently mentioning that linking mast cells to adhd. There haven't been studies on this demonstrating these connections directly. But one very insightful review by a group of interestingly complementary medicine practitioners in China published in 2020 that put forward the question could ADHD be a neuroinflammatory presentation involving mast cells? And here are all the reasons that I think support that claim. And it's really circling back to the earlier slides which show these connections. And again, you can look in more detail. We know that toxicity drives mast cells, drives inflammation, toxins are highly inflammatory and they get into the body in different ways and drive chaos. And with in terms of the autonomic nervous system. They damage barriers, gut barriers, blood brain barriers and cause toxicity in the brain. And is it possible that people with ADHD as a result of their immune dysfunction in many cases are like canaries in the mind. They get affected by toxicity earlier than most people. On a group level, not everyone's going to be in this camp. And to support that we've seen number of studies showing that there are multiple toxins that are linked to adhd from lead through to even paracetamol taken during pregnancy to pesticides and air pollution. Most of the time we study toxicity and we find its links with adhd. And this was in a very big document collating all the important evidence around ADHD published by Stephen Ferreau. I just want to draw attention to something that doesn't get much attention. Coming to the last part of the last few slides here. Indoor air toxicity is something that we don't look at enough. We often talk about outdoor air toxicity inside the home. There are many problems, increasing number of problems with the increasing chemicals that we bring into our lives and mold and the toxins that mold produces. I can tell you personally from personal experience and also from really diving deeply into this is a massive driver, a massively under recognized driver of illness, particularly neuropsychiatric illness. I think there are many people walking around with severe long standing chronic illness as a result of mold due to water related damage, powerful immune effects, powerful effects on the mast cells and environmental toxicity, whether it's mold, heavy metals, infections are working directly impacting the brain, but also through their impact on mast cells. Finally, I just want to draw attention to this genetic study. This was the latest study looking at in this case almost 40,000 people with ADHD and many more controls. And they're looking to see what genes or which genes stand out as being higher, more commonly present in those in the group with ADHD. And they found 27 essentially genes that crossed this line of significance. And what we read in the study was that these genes have lots of effects on the brain. Here in this column here I picked out three of these strongly linked genes you can see on the far column here. It shows that these are highly significant strong associations with adhd. And the study understandably focuses on all of the brain functions that these genes have. But if you dive deeper, you realize that genes don't just do one thing, they actually have multiple functions. And these genes just as an example and you can find many other ones of those 27 I've just picked out three have powerful immune related issues and issues linked to Connective tissue function I just listed here including mast cells, including hypermobility syndromes. But the point is I'm trying to make is that we find what we look for. If we're looking for stuff related to the brain, we'll find stuff related to the brain this first column. But if we broaden the search we realize that the problem is far broader than just the brain. It's a system wide issue. Anyway, that's enough from me. I just wanted to introduce you to my book. It's not specifically on these issues, although I do introduce these concepts and ideas. Is really more about how to live really well with ADHD and it's doing well. It's been top in Amazon for psychology and psychotherapy for on and off for the last few months and I encourage you to have a look and see if it interests you. As I said, I'm the medical director of the Grove Practice and we run various trainings. A one day workshop for individuals with ADHD or who suspect they have ADHD and then for professionals, a three day course called a Certificate in adhd. And the plus is for all of this other stuff that often doesn't get mentioned. Feel free to come along and have a look. The first cohort's full but we've got some new dates out there and to be honest, they're getting full as well. We are going to put more dates out if people are interested in. I want to thank you very much and I look forward to some questions.
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Thank you so much Dr. Cousteau for that brilliant presentation. Before we start the Q and A, I'd like to thank Inflow once more for sponsoring this webinar. And now to your questions. And can I just say we had over 300 questions, closer to 400. So that's how engaged people are. So the first question is does inflammation play a role in emotional dysregulation and what can people do to mitigate this.
- [50:38]
C
Inflammation can drive every symptom of adhd. There is a little bit of evidence suggesting that irritability is quite an inflammatory symptom. Not everybody who has ADHD will have this inflammatory picture, but a surprisingly high number of individuals do. I think the simple answer to the question is to try and map out what's going on. Try and map out what the source of the inflammation is, if there is indeed a source. Is this an allergy you didn't pick up? Do you have mold in your home? Are you reacting to certain foods causing inflammation? Did you get a parasitic infection when you went traveling? When you were in your 20s, do you have an unrecognized immune autoimmune problem? I think to work out how to reduce inflammation, it's important to try and work out where it's coming from. One of the mainstay treatments is of individuals with mast cell activation. And I'm certainly not suggesting people just dive in and do this on their own. But one of the mainstay treatments, once you've tried to identify the drivers and the triggers and the causes and manage those, is to quieten down the immune system, to quieten down what we refer to as the mast cell compartment. And that is done using certain foods and supplements. Antihistamines, and there's various different types of antihistamines, depending on which histamine receptor. There's the H1 antihistamines and the H2 antihistamines, which is famotidine, and then various what we term mast cell stabilizers. Again, supplements or medications that don't just block the histamine produced by the mast cells, but quieten down the actual activation and release of these chemicals. But this is not an area necessarily that one can approach on their own. And unfortunately, a lot of medical professionals simply don't know about this. And there remains quite a lot of controversy and unanswered questions. But many individuals who take antihistamines, often a double dose in the morning and the evening, experience dramatic improvements in multiple systems of their body, including of their ADHD and their anxiety and their mood disruption. But I'm certainly not suggesting to dive into this without professional guidance. It is complicated, but there's a lot of information out there to learn.
- [53:32]
B
That's fascinating. That's fascinating. And we haven't heard that before that I'm aware of. We had a question about could the hormonal shifts of childbearing, perimenopause and menopause act as catalysts for inflammation and some of these conditions you mentioned?
- [53:53]
C
Absolutely. 100%. The reduction in estrogen that takes place as you approach the menopause disrupts mast cells and often leads to an increase in inflammation that presents as ADHD symptoms. So it's not uncommon for a woman who's lived their life with a scattering of ADHD type traits. Their estrogen goes down, their mast cells get disrupted, and their ADHD symptoms are unmasked, increased to the point that a diagnosis is sometimes made at that stage. And women with adhd, established adhd, will very commonly report that their ADHD worsens. And my hypothesis, it needs more study, is that this is primarily Being driven through this mechanism. And also the week before the menstrual period, the changes in estrogen and progesterone are likely driving some inflammation in vulnerable individuals. Not everyone. You just haven't been looking in these areas because it's so new. It's not been within our frame, but it's definitely coming into the frame now. And it needs lots of research. It really does.
- [55:29]
B
Yes. I wanted to go back to. You talked about how clinicians aren't aware of all of these different factors. And someone wrote that she has gut health issues as well as ADHD and autism. And she wants to know how she can get her clinicians to consider that these are all related and not just separate disorders. How can she talk to her clinician?
- [56:02]
C
I think probably understanding herself how the various things might be linking together and gently trying to educate the clinicians or providing them with links or information. Maybe the map that I showed you, the somatic super syndrome map, and really trying to explain that the gastrointestinal problems that she's experiencing are most likely due to two factors. Assuming she fits into this group, and as I said, not everyone does. But if she does fit into this group, so say she had hypermobility and experienced dizziness and lightheadedness on standing. It's very likely. And allergies and inflammatory issues. It's very likely that the gut problems are being driven by two things primarily. One is dysautonomia. The autonomic nervous system is responsible for. For the peristaltic movement through the gut, moving through, through. If there's dysautonomia, there is a sluggish gut. In addition, mast cells in the gut that get activated cause swelling. Swelling limits flow. The combination of poor movement, poor peristaltic movement and inflammation causes the contents of the gut to stagnate. And we know that any liquid in any lumen or tube that doesn't flow will get. Will get infected, will get imbalanced, and then you get dysbiosis, and then you get toxicity. You get damage to the gut, the gut lining into the bloodstream, and you get further toxicity and the problems can spiral. But understanding the mechanisms by which that gut problem is happening and not seeing it as totally independent. Oh, I have some IBS unrelated to my ADHD is. The first point is trying to, as I said, take a step back, look at the connections and see the big picture. Because once you see this big picture, I tell you something, you can't unsee it.
- [58:23]
B
Okay, can you talk a little bit about diet? The Best kinds of diet for some of these conditions and whether supplements help in reducing inflammation.
- [58:36]
C
I think overall most of the evidence suggests that a Mediterranean diet, which is rich in colorful vegetables and green leafy vegetables, that has a good balance with lots of healthy fats and good quality protein in general is the diet that's associated with positive health benefits. Looking at all the studies across nutrition and that diversity in the diet is really important. So the take home message for gut health is I think diversity and reduce the process. The ultra processed foods increase the natural foods. However, people whose immune system is very sensitive often benefit from reducing gluten and reducing dairy. Not everyone, but that's worth a try. But whenever you restrict intake of certain food groups, you have to be extra careful not to drive deficiencies. People who work out that they are very sensitive to histamine and histamine is present in a whole load of foods. Any animal produce, whether it's fish or meat, the length of time from when the animal was killed through to when it's eaten, the histamine levels increase exponentially over that period of time. Certain vegetables, like spinach, like tomatoes, actually fruits, tomatoes, fruits like pineapples, strawberries, you might have noticed that tingle in your mouth when you eat certain fruits or vegetables. They're high in histamine and histamine causes the mast cells to go a bit chaotic. So start to notice when you experience anxiety or worsening of your adhd. Take a moment, what did you eat? What did you drink? What did you breathe? Which room did you go into? Start to make connections. Take a step back, look at these connections and test them. But don't radically reduce your diet so that you get deficiencies and other health problems. In that regard, get some guidance on it. Go and see a nutritional therapist, a functional medicine practitioner. I think there's a lot of people that understand this area, but there's a bit of catch up in the mainstream medical world, I'm afraid.
- [61:08]
B
Well, unfortunately that has to be our last question. But thank you so much for joining us today, Dr. Cousteau, and for sharing your expertise with our ADHD community. We appreciate it very much.
- [61:21]
C
Thank you, Carol. It's been very good talking to you.
- [61:25]
B
And thank you to today's listeners. If you would like to access the event resources, visit attitudemag.com and search podcast 54 5. The slides and recording are posted a few hours after each live webinar. If you're listening in replay mode, simply click on the episode description. Please know that our full library of attitude webinars is available as a podcast. It's called the ADHD Experts Podcast and it's available on most streaming platforms. We hope to see you again next week for for a very special roundtable discussion on living with adhd. It's different for Women. Attitude has convened a panel of leading experts to discuss the lived experiences of women with adhd, the critical need for research, and the importance of understanding and support. Click the link on screen to register today. Make sure you don't miss future Attitude webinars articles or or research updates by signing up to receive our free email newsletters@attitudemag.com newsletters thank you everyone and thank you so much, Dr. Cousteau.
- [62:38]
A
For more Attitude podcast and information on living well with attention deficit, visit attitudemag.com that's a D D I T U D e m a g.com.
- [62:57]
D
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