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Blanchette-Sarrasin A, Saj A. [Effects of non-invasive neuromodulation on the cognitive profile of people with anorexia nervosa: A scoping review]. L'ENCEPHALE 2024; 50:339-347. [PMID: 38087685 DOI: 10.1016/j.encep.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/13/2023] [Accepted: 11/02/2023] [Indexed: 05/31/2024]
Abstract
BACKGROUND The use of non-invasive neuromodulation is emerging in the treatment of anorexia nervosa. Despite promising results, further research is needed to improve our understanding of these techniques and to adapt interventions to this population. As anorexia nervosa is associated with several cognitive difficulties and cerebral anomalies, the aim of the present study was to summarize the available data on the effects of non-invasive neuromodulation on the neuropsychological profile of people with anorexia nervosa. METHOD A scoping review was conducted by searching in PsycINFO, PubMed and CINAHL databases to systematically identify relevant studies published between 1994 and 2023 on the treatment of anorexia nervosa with repetitive transcranial magnetic stimulation, transcranial direct current stimulation or neurofeedback electroencephalogram. RESULTS Seventeen articles were included, including 12 on repetitive transcranial magnetic stimulation, four on transcranial direct current stimulation and one on neurofeedback electroencephalogram. Of these, only three studies included a neuropsychological measure to assess the impact of neuromodulation on participants' cognitive functions. CONCLUSIONS Including detailed neuropsychological measures in clinical trials of non-invasive neuromodulation is highly recommended and appears essential to improve our understanding of these techniques and optimize their efficacy in the treatment of anorexia nervosa.
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Affiliation(s)
| | - Arnaud Saj
- Département de psychologie, Université de Montréal, Montréal, Québec, H3T 1J4, Canada; Centre de recherche interdisciplinaire en réadaptation (CRIR), Institut Nazareth et Louis-Braille du CISSS de la Montérégie-Centre, Longueuil, QC J4K 5G4, Canada; Centre interdisciplinaire de recherche sur le cerveau et l'apprentissage (CIRCA), Université de Montréal, Montréal, Québec, Canada; Laboratory for Behavioral Neurology and Imaging of Cognition, Neuroscience Department, University of Geneva, 1211 Geneva, Suisse; Département des neurosciences cliniques, Université de Genève, 1205 Genève, Suisse
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Ursumando L, Ponzo V, Monteleone AM, Menghini D, Fucà E, Lazzaro G, Esposito R, Picazio S, Koch G, Zanna V, Vicari S, Costanzo F. The efficacy of non-invasive brain stimulation in the treatment of children and adolescents with Anorexia Nervosa: study protocol of a randomized, double blind, placebo-controlled trial. J Eat Disord 2023; 11:127. [PMID: 37533058 PMCID: PMC10394844 DOI: 10.1186/s40337-023-00852-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/27/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Current psychological and pharmacological treatments for Anorexia Nervosa (AN) provide only moderate effective support, and there is an urgent need for research to improve therapies, especially in developing age. Non-invasive brain stimulation has suggested to have the potential to reducing AN symptomatology, via targeting brain alterations, such as hyperactivity of right prefrontal cortex (PFC). We suppose that transcranial direct current stimulation (tDCS) to the PFC may be effective in children and adolescents with AN. METHODS We will conduct a randomized, double blind, add-on, placebo-controlled trial to investigate the efficacy of tDCS treatment on clinical improvement. We will also investigate brain mechanisms and biomarkers changes acting in AN after tDCS treatment. Eighty children or adolescent with AN (age range 10-18 years) will undergo treatment-as-usual including psychiatric, nutritional and psychological support, plus tDCS treatment (active or sham) to PFC (F3 anode/F4 cathode), for six weeks, delivered three times a week. Psychological, neurophysiological and physiological measures will be collected at baseline and at the end of treatment. Participants will be followed-up one, three, six months and one year after the end of treatment. Psychological measures will include parent- and self-report questionnaires on AN symptomatology and other psychopathological symptoms. Neurophysiological measures will include transcranial magnetic stimulation (TMS) with electroencephalography and paired pulse TMS and repetitive TMS to investigate changes in PFC connectivity, reactivity and plasticity after treatment. Physiological measures will include changes in the functioning of the endogenous stress response system, body mass index (BMI) and nutritional state. DISCUSSION We expect that tDCS treatment to improve clinical outcome by reducing the symptoms of AN assessed as changes in Eating Disorder Risk composite score of the Eating Disorder Inventory-3. We also expect that at baseline there will be differences between the right and left hemisphere in some electrophysiological measures and that such differences will be reduced after tDCS treatment. Finally, we expect a reduction of endogenous stress response and an improvement in BMI and nutritional status after tDCS treatment. This project would provide scientific foundation for new treatment perspectives in AN in developmental age, as well as insight into brain mechanisms acting in AN and its recovery. Trial registration The study was registered at ClinicalTrials.gov (ID: NCT05674266) and ethical approval for the study was granted by the local research ethics committee (process number 763_OPBG_2014).
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Affiliation(s)
- Luciana Ursumando
- Child and Adolescent Neuropsychiatry Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio 4, 00165, Rome, Italy
| | - Viviana Ponzo
- Neurosurgery Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Deny Menghini
- Child and Adolescent Neuropsychiatry Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio 4, 00165, Rome, Italy
| | - Elisa Fucà
- Child and Adolescent Neuropsychiatry Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio 4, 00165, Rome, Italy
| | - Giulia Lazzaro
- Child and Adolescent Neuropsychiatry Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio 4, 00165, Rome, Italy
| | - Romina Esposito
- Experimental Neuropsychophysiology Lab, IRCCS S. Lucia Foundation, Rome, Italy
| | - Silvia Picazio
- Experimental Neuropsychophysiology Lab, IRCCS S. Lucia Foundation, Rome, Italy
- Department of Psychology, University "Sapienza" of Rome, Rome, Italy
| | - Giacomo Koch
- Experimental Neuropsychophysiology Lab, IRCCS S. Lucia Foundation, Rome, Italy
- Section of Human Phisiology, University of Ferrara, Ferrara, Italy
| | - Valeria Zanna
- Child and Adolescent Neuropsychiatry Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio 4, 00165, Rome, Italy
| | - Stefano Vicari
- Child and Adolescent Neuropsychiatry Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio 4, 00165, Rome, Italy
- Department of Life Science and Public Health, Catholic University of the Sacred Heart, 00168, Rome, Italy
| | - Floriana Costanzo
- Child and Adolescent Neuropsychiatry Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio 4, 00165, Rome, Italy.
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3
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Molina-Ruiz RM, Looi JCL, Walterfang M, García-Saiz T, Wilkes FA, Liu LL, Velakoulis D, Perera JLC, Diaz-Marsa M. Striatal volumes as potential biomarkers in Eating Disorders: A pilot study. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2022; 15:65-73. [PMID: 35840286 DOI: 10.1016/j.rpsmen.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 01/20/2020] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Differences in bulimic and impulsive behaviours in Eating Disorders (ED) have been associated with cortico-striatal circuit dysfunction at a neurobiological level. We sought to investigate neo-striatal volume as a biomarker in ED subgroups as well as the possible relationship with trauma history. MATERIAL AND METHODS We studied 24 female patients: Anorexia Nervosa AN (n=8), Bulimia Nervosa BN (n=9), comorbid ED with borderline personality disorder (EDc; n=7), and a group of Healthy Controls (n=19). Binge eating behaviours and impulsivity scales were used to characterize our sample as well as Trauma Questionnaires and Magnetic resonance imaging (MRI) volumetric manual measurements of caudate and putamen nuclei (striatum). RESULTS Our preliminary results showed a significantly larger left putaminal volume in AN compared to the other three groups [C (p=0.008), BN (p<.001) and EDc (p=.001)] and a smaller right putaminal volume in EDc compared to controls (p=.045) and AN (p=.039). Some negative correlations were found between bilateral putaminal volumes and self-reported general and early traumatization scores. CONCLUSION This pilot study suggested that striatal volumes might differentiate AN from BN and EDc at a neurobiological level with implications for treatment strategies. Larger scale studies should be carried out that allow replication of these data.
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Affiliation(s)
- Rosa M Molina-Ruiz
- Complutense University Medical School, Hospital Clínico San Carlos, Madrid, Spain.
| | - Jeffrey C L Looi
- Research Centre for Neurosciences of Ageing, Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra. Hospital, Canberra, Australia
| | - Mark Walterfang
- Neuropsychiatry Unit, Royal Melbourne Hospital; Melbourne Neuropsychiatry Centre, University of Melbourne and Northwestern Mental Health, Melbourne, Australia
| | | | - Fiona A Wilkes
- Research Centre for Neurosciences of Ageing, Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra. Hospital, Canberra, Australia
| | - Lena L Liu
- Research Centre for Neurosciences of Ageing, Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra. Hospital, Canberra, Australia
| | - Dennis Velakoulis
- Neuropsychiatry Unit, Royal Melbourne Hospital; Melbourne Neuropsychiatry Centre, University of Melbourne and Northwestern Mental Health, Melbourne, Australia
| | | | - Marina Diaz-Marsa
- Complutense University Medical School, Hospital Clínico San Carlos, Madrid, Spain
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4
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Pérez V, Villalba-Martínez G, Elices M, Manero RM, Salgado P, Ginés JM, Guardiola R, Cedrón C, Polo M, Delgado-Martínez I, Conesa G, Medrano S, Portella MJ. Cognitive and quality-of-life related factors of body mass index (BMI) improvement after deep brain stimulation in the subcallosal cingulate and nucleus accumbens in treatment-refractory chronic anorexia nervosa. EUROPEAN EATING DISORDERS REVIEW 2022; 30:353-363. [PMID: 35322504 DOI: 10.1002/erv.2895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 02/03/2022] [Accepted: 02/22/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Up to 20% of the cases of anorexia nervosa (AN) are chronic and treatment-resistant. Recently, the efficacy of deep brain stimulation (DBS) for severe cases of AN has been explored, with studies showing an improvement in body mass index and other psychiatric outcomes. While the effects of DBS on cognitive domains have been studied in patients with other neurological and psychiatric conditions so far, no evidence has been gathered in AN. METHODS Eight patients with severe, chronic, treatment-resistant AN received DBS either to the nucleus accumbens (NAcc) or subcallosal cingulate (SCC; four subjects on each target). A comprehensive battery of neuropsychological and clinical outcomes was used before and 6-month after surgery. FINDINGS Although Body Mass Index (BMI) did not normalise, statistically significant improvements in BMI, quality of life, and performance on cognitive flexibility were observed after 6 months of DBS. Changes in BMI were related to a decrease in depressive symptoms and an improvement in memory functioning. INTERPRETATION These findings, although preliminary, support the use of DBS in AN, pointing to its safety, even for cognitive functioning; improvements of cognitive flexibility are reported. DBS seems to exert changes on cognition and mood that accompany BMI increments. Further studies are needed better to determine the impact of DBS on cognitive functions.
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Affiliation(s)
- Víctor Pérez
- Institut de Neuropsiquiatria i Addiccions (INAD), Parc de Salut Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.,Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Parce de Salut Mar, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain
| | | | - Matilde Elices
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Parce de Salut Mar, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain
| | - Rosa María Manero
- Department of Neurology, Hospital del Mar, Barcelona, Catalonia, Spain
| | - Purificación Salgado
- Institut de Neuropsiquiatria i Addiccions (INAD), Parc de Salut Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - José María Ginés
- Institut de Neuropsiquiatria i Addiccions (INAD), Parc de Salut Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Rocío Guardiola
- Institut de Neuropsiquiatria i Addiccions (INAD), Parc de Salut Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Carlos Cedrón
- Institut de Neuropsiquiatria i Addiccions (INAD), Parc de Salut Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - María Polo
- Institut de Neuropsiquiatria i Addiccions (INAD), Parc de Salut Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | | | - Gerardo Conesa
- Department of Neurosurgery, Hospital del Mar, Barcelona, Spain
| | - Santiago Medrano
- Department of Radiology, Hospital del Mar, Barcelona, Catalonia, Spain
| | - Maria J Portella
- Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain.,Institut de d'Investigació Biomèdica Sant Pau. Hospital de la Santa Creu i Sant Pau. UAB, Barcelona, Catalonia, Spain
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5
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Coniglio KA, Cooper M, Selby EA. Behavioral reinforcement of pathological exercise in anorexia nervosa. Int J Eat Disord 2022; 55:184-192. [PMID: 34626127 DOI: 10.1002/eat.23626] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/29/2021] [Accepted: 09/29/2021] [Indexed: 12/29/2022]
Abstract
Pathological exercise in anorexia nervosa (AN) is a harmful behavior associated with a chronic course and poor prognosis. To date, no comprehensive theoretical model exists to describe pathological exercise in the context of AN, and as such, few treatments are effective at promoting direct and sustained pathological exercise extinction. Using a framework put forth by Wise & Koob (2014), debating the relative importance of positive and negative reinforcement in substance use, we present three hypotheses of behavioral reinforcement of exercise, encompassing biological, psychological, and environmental influences. Specifically, we argue that exercise is positively reinforced through receipt of biological and behavioral rewards, negatively reinforced through avoidance of aversive emotions, and that these two systems work in tandem over time to engrain pathological exercise as a habit. We then present suggestions for testing each of these hypotheses as future directions for the field.
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Affiliation(s)
- Kathryn A Coniglio
- Department of Psychology, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Marita Cooper
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Edward A Selby
- Department of Psychology, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
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6
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Alfano V, Mele G, Cotugno A, Longarzo M. Multimodal neuroimaging in anorexia nervosa. J Neurosci Res 2020; 98:2178-2207. [PMID: 32770570 DOI: 10.1002/jnr.24674] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/26/2020] [Accepted: 05/25/2020] [Indexed: 12/13/2022]
Abstract
Anorexia nervosa (AN) is a severe and complex psychiatric disorder characterized by intense fear about weight gain and finalized to food-related control behaviors. Growing interest has been demonstrated about neurobiological processes subtend to AN physiopathology. The present review aimed to collect neurostructural and neurofunctional available data from 2010 to 2019. Results have been organized according to the neuroimaging technique employed, also including a specific section on electroencephalographic results, mostly neglected in previous reviews. Diffuse cerebral vulnerability has been demonstrated and the contribution of several structures has been identified. Insula, cingulate cortex, parietal and frontal areas are primarily involved both by structural and functional perspectives. Moreover, consistent alterations in white matter integrity and brain electrical activity have been reported. Neuroimaging findings give a substantial contribution to AN pathophysiological description, also in order to understand altered but reversible processes in the passage from acute illness phase to disorder's remission, useful also for defining therapy.
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7
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Matiz A, Guzzon D, Crescentini C, Paschetto A, Fabbro F. The role of self body brushing vs mindfulness meditation on interoceptive awareness: A non-randomized pilot study on healthy participants with possible implications for body image disturbances. Eur J Integr Med 2020. [DOI: 10.1016/j.eujim.2020.101168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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8
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Villalba Martínez G, Justicia A, Salgado P, Ginés JM, Guardiola R, Cedrón C, Polo M, Delgado-Martínez I, Medrano S, Manero RM, Conesa G, Faus G, Grau A, Elices M, Pérez V. A Randomized Trial of Deep Brain Stimulation to the Subcallosal Cingulate and Nucleus Accumbens in Patients with Treatment-Refractory, Chronic, and Severe Anorexia Nervosa: Initial Results at 6 Months of Follow Up. J Clin Med 2020; 9:jcm9061946. [PMID: 32580399 PMCID: PMC7357090 DOI: 10.3390/jcm9061946] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 06/12/2020] [Accepted: 06/16/2020] [Indexed: 01/28/2023] Open
Abstract
Background: The main objective of this study was to assess the safety and efficacy of deep brain stimulation (DBS) in patients with severe anorexia nervosa (AN). Methods: Eight participants received active DBS to the subcallosal cingulate (SCC) or nucleus accumbens (NAcc) depending on comorbidities (affective or anxiety disorders, respectively) and type of AN. The primary outcome measure was body mass index (BMI). Results: Overall, we found no significant difference (p = 0.84) between mean preoperative and postoperative (month 6) BMI. A BMI reference value (BMI-RV) was calculated. In patients that received preoperative inpatient care to raise the BMI, the BMI-RV was defined as the mean BMI value in the 12 months prior to surgery. In patients that did not require inpatient care, the BMI-RV was defined as the mean BMI in the 3-month period before surgery. This value was compared to the postoperative BMI (month 6), revealing a significant increase (p = 0.02). After 6 months of DBS, five participants showed an increase of ≥10% in the BMI-RV. Quality of life was improved (p = 0.03). Three cases presented cutaneous complications. Conclusion: DBS may be effective for some patients with severe AN. Cutaneous complications were observed. Longer term data are needed.
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Affiliation(s)
- Gloria Villalba Martínez
- Department of Neurosurgery, Hospital del Mar, 08003 Barcelona, Spain; (G.V.M.); (I.D.-M.); (G.C.)
- Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, 08193 Barcelona, Spain;
| | - Azucena Justicia
- Hospital del Mar Medical Research Institute (IMIM), 08003 Barcelona, Spain;
- Institut de Neuropsiquiatria i Adiccions (INAD), Hospital del Mar, 08003 Barcelona, Spain; (P.S.); (J.M.G.); (R.G.); (C.C.); (M.P.)
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), 28029 Madrid, Spain
| | - Purificación Salgado
- Institut de Neuropsiquiatria i Adiccions (INAD), Hospital del Mar, 08003 Barcelona, Spain; (P.S.); (J.M.G.); (R.G.); (C.C.); (M.P.)
| | - José María Ginés
- Institut de Neuropsiquiatria i Adiccions (INAD), Hospital del Mar, 08003 Barcelona, Spain; (P.S.); (J.M.G.); (R.G.); (C.C.); (M.P.)
| | - Rocío Guardiola
- Institut de Neuropsiquiatria i Adiccions (INAD), Hospital del Mar, 08003 Barcelona, Spain; (P.S.); (J.M.G.); (R.G.); (C.C.); (M.P.)
| | - Carlos Cedrón
- Institut de Neuropsiquiatria i Adiccions (INAD), Hospital del Mar, 08003 Barcelona, Spain; (P.S.); (J.M.G.); (R.G.); (C.C.); (M.P.)
| | - María Polo
- Institut de Neuropsiquiatria i Adiccions (INAD), Hospital del Mar, 08003 Barcelona, Spain; (P.S.); (J.M.G.); (R.G.); (C.C.); (M.P.)
| | - Ignacio Delgado-Martínez
- Department of Neurosurgery, Hospital del Mar, 08003 Barcelona, Spain; (G.V.M.); (I.D.-M.); (G.C.)
| | - Santiago Medrano
- Department of Radiology, Hospital del Mar, 08003 Barcelona, Spain;
| | | | - Gerardo Conesa
- Department of Neurosurgery, Hospital del Mar, 08003 Barcelona, Spain; (G.V.M.); (I.D.-M.); (G.C.)
- Hospital del Mar Medical Research Institute (IMIM), 08003 Barcelona, Spain;
- Department of Surgery, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, 08193 Barcelona, Spain
| | - Gustavo Faus
- ITA, Mental Health Specialists, 08036 Barcelona, Spain; (G.F.); (A.G.)
| | - Antoni Grau
- ITA, Mental Health Specialists, 08036 Barcelona, Spain; (G.F.); (A.G.)
| | - Matilde Elices
- Hospital del Mar Medical Research Institute (IMIM), 08003 Barcelona, Spain;
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), 28029 Madrid, Spain
- Correspondence: ; Tel.: +34-933160
| | - Víctor Pérez
- Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, 08193 Barcelona, Spain;
- Hospital del Mar Medical Research Institute (IMIM), 08003 Barcelona, Spain;
- Institut de Neuropsiquiatria i Adiccions (INAD), Hospital del Mar, 08003 Barcelona, Spain; (P.S.); (J.M.G.); (R.G.); (C.C.); (M.P.)
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), 28029 Madrid, Spain
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9
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Molina-Ruiz RM, Looi JCL, Walterfang M, García-Saiz T, Wilkes FA, Liu LL, Velakoulis D, Perera JLC, Diaz-Marsa M. Striatal volumes as potential biomarkers in Eating Disorders: A pilot study. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2020; 15:S1888-9891(20)30022-7. [PMID: 32513624 DOI: 10.1016/j.rpsm.2020.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 10/02/2019] [Accepted: 01/20/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Differences in bulimic and impulsive behaviours in Eating Disorders (ED) have been associated with cortico-striatal circuit dysfunction at a neurobiological level. We sought to investigate neo-striatal volume as a biomarker in ED subgroups as well as the possible relationship with trauma history. MATERIAL AND METHODS We studied 24 female patients: Anorexia Nervosa AN (n=8), Bulimia Nervosa BN (n=9), comorbid ED with borderline personality disorder (EDc; n=7), and a group of Healthy Controls (n=19). Binge eating behaviours and impulsivity scales were used to characterize our sample as well as Trauma Questionnaires and Magnetic resonance imaging (MRI) volumetric manual measurements of caudate and putamen nuclei (striatum). RESULTS Our preliminary results showed a significantly larger left putaminal volume in AN compared to the other three groups [C (p=0.008), BN (p<.001) and EDc (p=.001)] and a smaller right putaminal volume in EDc compared to controls (p=.045) and AN (p=.039). Some negative correlations were found between bilateral putaminal volumes and self-reported general and early traumatization scores. CONCLUSION This pilot study suggested that striatal volumes might differentiate AN from BN and EDc at a neurobiological level with implications for treatment strategies. Larger scale studies should be carried out that allow replication of these data.
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Affiliation(s)
- Rosa M Molina-Ruiz
- Complutense University Medical School, Hospital Clínico San Carlos, Madrid, Spain.
| | - Jeffrey C L Looi
- Research Centre for Neurosciences of Ageing, Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra. Hospital, Canberra, Australia
| | - Mark Walterfang
- Neuropsychiatry Unit, Royal Melbourne Hospital; Melbourne Neuropsychiatry Centre, University of Melbourne and Northwestern Mental Health, Melbourne, Australia
| | | | - Fiona A Wilkes
- Research Centre for Neurosciences of Ageing, Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra. Hospital, Canberra, Australia
| | - Lena L Liu
- Research Centre for Neurosciences of Ageing, Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra. Hospital, Canberra, Australia
| | - Dennis Velakoulis
- Neuropsychiatry Unit, Royal Melbourne Hospital; Melbourne Neuropsychiatry Centre, University of Melbourne and Northwestern Mental Health, Melbourne, Australia
| | | | - Marina Diaz-Marsa
- Complutense University Medical School, Hospital Clínico San Carlos, Madrid, Spain
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10
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Cascino G, Canna A, Monteleone AM, Russo AG, Prinster A, Aiello M, Esposito F, Salle FD, Monteleone P. Cortical thickness, local gyrification index and fractal dimensionality in people with acute and recovered Anorexia Nervosa and in people with Bulimia Nervosa. Psychiatry Res Neuroimaging 2020; 299:111069. [PMID: 32203897 DOI: 10.1016/j.pscychresns.2020.111069] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 03/11/2020] [Accepted: 03/14/2020] [Indexed: 01/12/2023]
Abstract
Eating disorders (EDs) have a possible neurodevelopmental pathogenesis. Our study aim was to assess regional cortical thickness (CT), local gyrification index (lGI) and fractal dimensionality (FD), as specific markers of cortical neurodevelopment in ED females. Twenty-two women with acute anorexia nervosa (acuAN), 10 with recovered anorexia nervosa (recAN), 24 with bulimia nervosa (BN) and 35 female healthy controls (HC) underwent a 3T MRI scan. All data were processed by FreeSurfer. Compared to recAN group women with acuAN showed a lower CT in multiple areas, while compared to HC they showed lower CT in temporal regions. BN group showed higher CT values in temporal and paracentral areas compared to HC. In multiple cortical areas, AcuAN group showed greater values of lGI compared to recAN group and lower values of lGI compared to HC. The BN group showed lower lGI in left medial orbitofrontal cortex compared to HC. No significant differences were found in FD among the groups. Present results provide evidence of CT and lGI alterations in patients with AN and, for the first time, in those with BN. Although these alterations could be state-dependent phenomena, they may underlie psychopathological aspects of EDs.
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Affiliation(s)
- Giammarco Cascino
- Department of Medicine, Surgery and Dentistry 'Scuola Medica Salernitana', University of Salerno, Via Salvador Allende, 84081 Baronissi, Italy.
| | - Antonietta Canna
- Department of Medicine, Surgery and Dentistry 'Scuola Medica Salernitana', University of Salerno, Via Salvador Allende, 84081 Baronissi, Italy
| | | | - Andrea Gerardo Russo
- Department of Medicine, Surgery and Dentistry 'Scuola Medica Salernitana', University of Salerno, Via Salvador Allende, 84081 Baronissi, Italy
| | - Anna Prinster
- Biostructure and Bioimaging Institute, National Research Council, Naples, Italy
| | | | - Fabrizio Esposito
- Department of Medicine, Surgery and Dentistry 'Scuola Medica Salernitana', University of Salerno, Via Salvador Allende, 84081 Baronissi, Italy
| | - Francesco Di Salle
- Department of Medicine, Surgery and Dentistry 'Scuola Medica Salernitana', University of Salerno, Via Salvador Allende, 84081 Baronissi, Italy
| | - Palmiero Monteleone
- Department of Medicine, Surgery and Dentistry 'Scuola Medica Salernitana', University of Salerno, Via Salvador Allende, 84081 Baronissi, Italy
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11
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Molina-Ruiz RM, García-Saiz T, Looi JCL, Via Virgili E, Rincón Zamorano M, de Anta Tejado L, López HT, Perera JLC, Díaz-Marsá M. Neural Mechanisms in Eating Behaviors: A Pilot fMRI Study of Emotional Processing. Psychiatry Investig 2020; 17:225-236. [PMID: 32160692 PMCID: PMC7113175 DOI: 10.30773/pi.2019.0038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 10/14/2019] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Emotional processing dysfunction evident in eating disorders (ED) such as anorexia nervosa (AN) and bulimia nervosa (BN), is considered relevant to the development and maintenance of these disorders. The purpose of the current functional magnetic resonance imaging (fMRI) study was to pilot a comparison of the activity of the fronto-limbic and fronto-striatal brain areas during an emotion processing task in persons with ED. METHODS 24 women patients with ED were scanned, while showing emotionally stimulating (pleasant, unpleasant) and neutral images from the International Affective Picture System (IAPS). RESULTS During the pleasant condition, significant differences in Dorsolateral Prefrontal Cortex (DLPFC) activations were found with AN participants presenting greater activation compared to BN and ED comorbid groups (EDc) and healthy controls also showing greater activation of this brain area compared to BN and EDc. Left putamen was less activated in EDc compared to both controls (C) and AN. During the unpleasant condition, AN participants showed hyperactivation of the Orbito-frontal Cortex (OFC) when compared to EDc. CONCLUSION This study highlights the potential functional relevance of brain areas that have been associated with self-control. These findings should help advance understanding the neural substrate of ED, though they should be considered as preliminary and be cautiously interpreted.
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Affiliation(s)
- Rosa M Molina-Ruiz
- Psychiatry Department, Universitary Hospital Clinico San Carlos de Madrid, IddISC, Madrid, Spain
| | - T García-Saiz
- Artificial Intelligence Department, UNED. E.T.S.I. Informatics, Madrid, Spain
| | - Jeffrey C L Looi
- Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra Hospital, Canberra, Australia
| | - E Via Virgili
- Hospital Materno-Infantil Sant Joan de Déu, Barcelona, Spain
| | - M Rincón Zamorano
- Artificial Intelligence Department, UNED. E.T.S.I. Informatics, Madrid, Spain
| | - Laura de Anta Tejado
- Psychiatry Department, Universitary Hospital Clinico San Carlos de Madrid, IddISC, Madrid, Spain
| | - Helena Trebbau López
- Psychiatry Department, Universitary Hospital Clinico San Carlos de Madrid, IddISC, Madrid, Spain
| | | | - Marina Díaz-Marsá
- Psychiatry Department, Universitary Hospital Clinico San Carlos de Madrid, IddISC, Madrid, Spain
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12
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Deficits in response inhibition on varied levels of demand load in anorexia nervosa: an event-related potentials study. Eat Weight Disord 2020; 25:231-240. [PMID: 30168032 PMCID: PMC6997249 DOI: 10.1007/s40519-018-0558-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 07/30/2018] [Indexed: 10/28/2022] Open
Abstract
PURPOSE The aim of the present study was to investigate the executive function of inhibitory control in anorexia nervosa (AN), which is considered as an underlying pathophysiology of restricting eating. METHODS In this work, we examined the function of response inhibition in 27 unmedicated AN patients and 30 healthy controls (HC) using stop-signal tasks with different demand loads. Two event-related potentials (ERP) during the stop-signal tasks, N2 and P300, were compared between the AN and HC groups. RESULTS We found attenuated P300 amplitudes and delayed N2 latencies in AN patients across all three demand loads compared to HCs. We also found significant interaction between group and level of demand load. N2 latencies were prolonged when the inhibitory demand was lower in the AN group, whereas no differences in N2 latencies were found across different demand loads in HCs. CONCLUSIONS Taken together, altered P300 amplitudes and N2 latencies may be associated with impaired response inhibition in AN patients. In particular, alterations of fronto-central N2 activations were demand-related, which might contribute to an aberrant inhibitory control process in AN. LEVEL OF EVIDENCE Level II, controlled trial without randomization.
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13
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van Zutphen L, Maier S, Siep N, Jacob GA, Tüscher O, van Elst LT, Zeeck A, Arntz A, O'Connor MF, Stamm H, Hudek M, Joos A. Intimate stimuli result in fronto-parietal activation changes in anorexia nervosa. Eat Weight Disord 2019; 24:1155-1164. [PMID: 29397562 DOI: 10.1007/s40519-017-0474-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 12/18/2017] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Intimacy is a key psychological problem in anorexia nervosa (AN). Empirical evidence, including neurobiological underpinnings, is however, scarce. OBJECTIVE In this study, we evaluated various emotional stimuli including intimate stimuli experienced in patients with AN and non-patients, as well as their cerebral response. METHODS Functional magnetic resonance imaging was conducted using stimuli with positive, neutral, negative and intimate content. Participants (14 AN patients and 14 non-patients) alternated between passive viewing and explicit emotion regulation. RESULTS Intimate stimuli were experienced less positively in AN patients compared to non-patients. AN patients showed decreased cerebral responses in superior parietal cortices in response to positive and intimate stimuli. Intimate stimuli led to stronger activation of the orbitofrontal cortex, and lower activation of the bilateral precuneus in AN patients. Orbitofrontal responses decreased in AN patients during explicit emotion regulation. CONCLUSIONS These results show that intimate stimuli are of particular importance in AN patients, who show experiential differences compared to non-patients and altered activation of orbitofrontal and parietal brain structures. This supports that AN patients have difficulties with intimacy, attachment, self-referential processing and body perception. LEVEL OF EVIDENCE Level III, case-control study.
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Affiliation(s)
- L van Zutphen
- Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands
| | - S Maier
- Department of Psychosomatic Medicine and Psychotherapy, Medical Center, University of Freiburg Faculty of Medicine, University of Freiburg, Hauptstraße 8, 79104, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center, University of Freiburg Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - N Siep
- Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands
| | - G A Jacob
- Institute of Psychology, University of Freiburg, Freiburg, Germany
| | - O Tüscher
- Department of Psychiatry and Psychotherapy, University of Mainz, Mainz, Germany
| | - L Tebartz van Elst
- Department of Psychiatry and Psychotherapy, Medical Center, University of Freiburg Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - A Zeeck
- Department of Psychosomatic Medicine and Psychotherapy, Medical Center, University of Freiburg Faculty of Medicine, University of Freiburg, Hauptstraße 8, 79104, Freiburg, Germany
| | - A Arntz
- Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands.,Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - M-F O'Connor
- Department of Psychology, University of Arizona, Tucson, USA
| | - H Stamm
- Department of Psychosomatic Medicine and Psychotherapy, Medical Center, University of Freiburg Faculty of Medicine, University of Freiburg, Hauptstraße 8, 79104, Freiburg, Germany
| | - M Hudek
- Department of Psychosomatic Medicine and Psychotherapy, Medical Center, University of Freiburg Faculty of Medicine, University of Freiburg, Hauptstraße 8, 79104, Freiburg, Germany
| | - Andreas Joos
- Department of Psychosomatic Medicine and Psychotherapy, Medical Center, University of Freiburg Faculty of Medicine, University of Freiburg, Hauptstraße 8, 79104, Freiburg, Germany. .,Department of Psychotherapeutic Neurology, Kliniken Schmieder Gailingen, Gailingen, Germany.
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14
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Collantoni E, Meneguzzo P, Solmi M, Tenconi E, Manara R, Favaro A. Functional Connectivity Patterns and the Role of 5-HTTLPR Polymorphism on Network Architecture in Female Patients With Anorexia Nervosa. Front Neurosci 2019; 13:1056. [PMID: 31680805 PMCID: PMC6802575 DOI: 10.3389/fnins.2019.01056] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 09/19/2019] [Indexed: 12/21/2022] Open
Abstract
Introduction Recent neuroimaging studies suggest that anorexia nervosa (AN) symptoms emerge from failures in the relationships between spatially distributed networks that support different cognitive, emotional, and somatosensory functions. The 5-HTTLPR genotype has been shown to modulate all these abilities in AN, as well as the connectivity patterns between brain regions that support their functioning. This study aims at exploring the presence of any difference in functional connectome properties between AN patients and healthy controls (HC) by means of graph theory tools. The effect of 5-HTTLPR genotype on regional and global network characteristics in AN and HC was also explored. Methods A sample of 74 subjects (38 HC, 36 AN) underwent a resting state functional magnetic resonance imaging and was genotyped for 5-HTTLPR polymorphism. Comparisons of network properties were made between the AN and HC groups and, within each group, between 5-HTTLPR carriers of low-functioning alleles and carriers of the long–long genotype. Results Patients with AN displayed lower network clustering than HC (p = 0.04 at Mann–Whitney U test). Based on both degree and betweenness, a different distribution of network hubs emerged in the two groups. In particular, the anterior part of the anterior cingulate cortex was a hub only in the patient group. A correlation emerged between differences in brain volumes between patients and HC and differences in degree values of basal ganglia, nodes in the insula, and those in the parietal cortex. Carriers of the short allele of the 5-HTTLPR polymorphism were characterized by lower small-world properties (p = 0.027) and modularity (p = 0.031) in the patient group, and a trend toward higher modularity (p = 0.033) and small-world values (p = 0.123) in the HC group. Discussion Patients with AN showed differences in hubs distribution, providing evidence of the presence of a different functional architectural backbone in this group. Since some correlation emerged between different degree values of nodes and differences in volumes, further longitudinal studies are warranted to better understand the role of malnutrition on brain network architecture. The opposite effects of 5-HTTLPR polymorphism on global network characteristics in the two groups suggest an interaction of the short allele and malnutrition in modulating brain network properties.
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Affiliation(s)
| | - Paolo Meneguzzo
- Department of Neurosciences, University of Padua, Padua, Italy
| | - Marco Solmi
- Department of Neurosciences, University of Padua, Padua, Italy.,Padova Neuroscience Center, University of Padua, Padua, Italy
| | - Elena Tenconi
- Department of Neurosciences, University of Padua, Padua, Italy.,Padova Neuroscience Center, University of Padua, Padua, Italy
| | - Renzo Manara
- Radiology Unit, Department of Medicine and Surgery, Neuroscience Section, University of Salerno, Salerno, Italy
| | - Angela Favaro
- Department of Neurosciences, University of Padua, Padua, Italy.,Padova Neuroscience Center, University of Padua, Padua, Italy
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15
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Costanzo F, Menghini D, Maritato A, Castiglioni MC, Mereu A, Varuzza C, Zanna V, Vicari S. New Treatment Perspectives in Adolescents With Anorexia Nervosa: The Efficacy of Non-invasive Brain-Directed Treatment. Front Behav Neurosci 2018; 12:133. [PMID: 30083095 PMCID: PMC6064943 DOI: 10.3389/fnbeh.2018.00133] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 06/13/2018] [Indexed: 01/29/2023] Open
Abstract
Poor treatment outcomes are available for anorexia nervosa (AN) and treatment innovations are urgently needed. Recently, non-invasive neuromodulation tools have suggested to have potential for reducing an symptomatology targeting brain alterations. The objective of the study was to verify whether left anodal/right cathodal prefrontal cortex transcranial direct current stimulation (tDCS), may aid in altering/resetting inter-hemispheric balance in patients with AN, re-establishing control over eating behaviors. Twenty-three adolescents with an underwent a treatment as usual (AU), including nutritional, pharmacological, and psychoeducational treatment, plus 18 sessions of tDCS (TDCS+AU = n11; mean age = 13.9, SD = 1.8 years) or a family based therapy (FBT+AU = n12, mean age = 15.1, SD = 1.5 years). Psychopathological scales and the body mass index (BMI) were assessed before and after treatment. After 6 weeks of treatment, the BMI values increased only in the tDCS group, even at 1-month follow-up. Independently of the treatment, all participants improved in several psychopathological measures, included AN psychopathology and mood and anxiety symptoms. Our results demonstrated for the first time a specific effect of the left anodal/right cathodal tDCS treatment protocol on stable weight gain and a superiority compared to an active control treatment for adolescents with AN. Results were interpreted as a possible direct/indirect effect of tDCS in into some pathophysiological mechanisms of AN, involving the mesocortical dopaminergic pathways and the promotion of food intake. This pilot study opens new perspectives in the treatment of an in adolescence, supporting the targeted and beneficial effects of a brain-based treatment.
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Affiliation(s)
- Floriana Costanzo
- Child Neuropsychiatric Unit, Department of Neuroscience, Bambino Gesù Children Hospital, Rome, Italy
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16
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Neural processing of food and emotional stimuli in adolescent and adult anorexia nervosa patients. PLoS One 2018; 13:e0191059. [PMID: 29579064 PMCID: PMC5868769 DOI: 10.1371/journal.pone.0191059] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 12/26/2017] [Indexed: 02/07/2023] Open
Abstract
Background A constant preoccupation with food and restrictive eating are main symptoms of anorexia nervosa (AN). Imaging studies revealed aberrant neural activation patterns in brain regions processing hedonic and reward reactions as well as–potentially aversive–emotions. An imbalance between so called “bottom-up” and “top-down” control areas is discussed. The present study is focusing on neural processing of disease-specific food stimuli and emotional stimuli and its developmental course in adolescent and adult AN patients and could offer new insight into differential mechanisms underlying shorter or more chronic disease. Methods 33 adolescents aged 12–18 years (15 AN patients, 18 control participants) and 32 adult women (16 AN patients, 16 control participants) underwent functional magnetic resonance imaging (fMRI, 3T high-field scanner) while watching pictures of high and low-calorie food and affective stimuli. Afterwards, they rated subjective valence of each picture. FMRI data analysis was performed using a region of interest based approach. Results Pictures of high-calorie food items were rated more negatively by AN patients. Differences in activation between patients and controls were found in “bottom up” and “top down” control areas for food stimuli and in several emotion processing regions for affective stimuli which were more pronounced in adolescents than in adults. Conclusion A differential pattern was seen for food stimuli compared to generally emotion eliciting stimuli. Adolescents with AN show reduced processing of affective stimuli and enhanced activation of regions involved in “bottom up” reward processing and “top down” control as well as the insula with regard to food stimuli with a focus on brain regions which underlie changes during adolescent development. In adults less clear and less specific activation differences were present, pointing towards a high impact that regions undergoing maturation might have on AN symptoms.
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17
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Foldi CJ, Milton LK, Oldfield BJ. The Role of Mesolimbic Reward Neurocircuitry in Prevention and Rescue of the Activity-Based Anorexia (ABA) Phenotype in Rats. Neuropsychopharmacology 2017; 42:2292-2300. [PMID: 28322236 PMCID: PMC5645746 DOI: 10.1038/npp.2017.63] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 02/23/2017] [Accepted: 03/01/2017] [Indexed: 02/07/2023]
Abstract
Patients suffering from anorexia nervosa (AN) become anhedonic; unable or unwilling to derive normal pleasures and avoid rewarding outcomes, most profoundly in food intake. The activity-based anorexia (ABA) model recapitulates many of the characteristics of the human condition, including anhedonia, and allows investigation of the underlying neurobiology of AN. The potential for increased neuronal activity in reward/hedonic circuits to prevent and rescue weight loss is investigated in this model. The mesolimbic pathway extending from the ventral tegmental area (VTA) to the nucleus accumbens (NAc) was activated using a dual viral strategy, involving retrograde transport of Cre (CAV-2-Cre) to the VTA and coincident injection of DREADD receptors (AAV-hSyn-DIO-hM3D(Gq)-mCherry). Systemic clozapine-n-oxide (CNO; 0.3 mg/kg) successfully recruited a large proportion of the VTA-NAc dopaminergic projections, with activity evidenced by colocalization with elevated levels of Fos protein. The effects of reward circuit activation on energy balance and predicted survival was investigated in female Sprague-Dawley rats, where free access to running wheels was paired with time-limited (90 min) access to food, a paradigm (ABA) which will cause anorexia and death if unchecked. Excitation of the reward pathway substantially increased food intake and food anticipatory activity (FAA) to prevent ABA-associated weight loss, while overall locomotor activity was unchanged. Similar activation of reward circuitry, delayed until establishment of the ABA phenotype, rescued rats from their precipitous weight loss. Although these data are consistent with shifts primarily in food intake, the contribution of mechanisms including energy expenditure to survival remains to be determined. These results will inform the neurobiological underpinnings of AN, and provide insight into the mechanisms of reward circuitry relevant to feeding and weight loss.
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Affiliation(s)
- Claire J Foldi
- Department of Physiology, Monash University, Clayton, VIC, Australia
| | - Laura K Milton
- Department of Physiology, Monash University, Clayton, VIC, Australia
| | - Brian J Oldfield
- Department of Physiology, Monash University, Clayton, VIC, Australia,Department of Physiology, Monash University, 26 Innovation Walk, Clayton, VIC 3800, Australia, Tel: +61 3 990 52507, Fax: +61 3 990 20707, E-mail:
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18
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Foldi CJ, Milton LK, Oldfield BJ. A focus on reward in anorexia nervosa through the lens of the activity-based anorexia rodent model. J Neuroendocrinol 2017; 29. [PMID: 28475260 DOI: 10.1111/jne.12479] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 04/27/2017] [Accepted: 04/30/2017] [Indexed: 12/19/2022]
Abstract
Patients suffering anorexia nervosa (AN) become anhedonic, unable or unwilling to derive normal pleasures and tend to avoid rewarding outcomes, most profoundly in food intake. The activity-based anorexia model recapitulates many of the pathophysiological and behavioural hallmarks of the human condition, including a reduction in food intake, excessive exercise, dramatic weight loss, loss of reproductive cycles, hypothermia and anhedonia, and therefore it allows investigation into the underlying neurobiology of anorexia nervosa. The use of this model has directed attention to disruptions in central reward neurocircuitry, which may contribute to disease susceptibility. The purpose of this review is to demonstrate the utility of this unique model to provide insight into the mechanisms of reward relevant to feeding and weight loss, which may ultimately help to unravel the neurobiology of anorexia nervosa and, in a broader sense, the foundation of reward-based feeding.
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Affiliation(s)
- C J Foldi
- Department of Physiology, Monash University, Clayton, VIC, Australia
| | - L K Milton
- Department of Physiology, Monash University, Clayton, VIC, Australia
| | - B J Oldfield
- Department of Physiology, Monash University, Clayton, VIC, Australia
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19
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Geisler D, Ritschel F, King JA, Bernardoni F, Seidel M, Boehm I, Runge F, Goschke T, Roessner V, Smolka MN, Ehrlich S. Increased anterior cingulate cortex response precedes behavioural adaptation in anorexia nervosa. Sci Rep 2017; 7:42066. [PMID: 28198813 PMCID: PMC5304157 DOI: 10.1038/srep42066] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 12/07/2016] [Indexed: 01/28/2023] Open
Abstract
Patients with anorexia nervosa (AN) are characterised by increased self-control, cognitive rigidity and impairments in set-shifting, but the underlying neural mechanisms are poorly understood. Here we used functional magnetic resonance imaging (fMRI) to elucidate the neural correlates of behavioural adaptation to changes in reward contingencies in young acutely ill AN patients. Thirty-six adolescent/young adult, non-chronic female AN patients and 36 age-matched healthy females completed a well-established probabilistic reversal learning task during fMRI. We analysed hemodynamic responses in empirically-defined regions of interest during positive feedback and negative feedback not followed/followed by behavioural adaptation and conducted functional connectivity analyses. Although overall task performance was comparable between groups, AN showed increased shifting after receiving negative feedback (lose-shift behaviour) and altered dorsal anterior cingulate cortex (dACC) responses as a function of feedback. Specifically, patients had increased dACC responses (which correlated with perfectionism) and task-related coupling with amygdala preceding behavioural adaption. Given the generally preserved task performance in young AN, elevated dACC responses specifically during behavioural adaption is suggestive of increased monitoring for the need to adjust performance strategies. Higher dACC-amygdala coupling and increased adaptation after negative feedback underlines this interpretation and could be related to intolerance of uncertainty which has been suggested for AN.
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Affiliation(s)
- Daniel Geisler
- Division of Psychological and Social Medicine and Developmental Neuroscience, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany.,Eating Disorder Treatment and Research Center, Department of Child and Adolescent Psychiatry, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Franziska Ritschel
- Division of Psychological and Social Medicine and Developmental Neuroscience, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany.,Eating Disorder Treatment and Research Center, Department of Child and Adolescent Psychiatry, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Joseph A King
- Division of Psychological and Social Medicine and Developmental Neuroscience, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany.,Eating Disorder Treatment and Research Center, Department of Child and Adolescent Psychiatry, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Fabio Bernardoni
- Division of Psychological and Social Medicine and Developmental Neuroscience, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany.,Eating Disorder Treatment and Research Center, Department of Child and Adolescent Psychiatry, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Maria Seidel
- Division of Psychological and Social Medicine and Developmental Neuroscience, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany.,Eating Disorder Treatment and Research Center, Department of Child and Adolescent Psychiatry, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Ilka Boehm
- Division of Psychological and Social Medicine and Developmental Neuroscience, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany.,Eating Disorder Treatment and Research Center, Department of Child and Adolescent Psychiatry, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Franziska Runge
- Division of Psychological and Social Medicine and Developmental Neuroscience, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany.,Eating Disorder Treatment and Research Center, Department of Child and Adolescent Psychiatry, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Thomas Goschke
- Department of Psychology, Institute of General Psychology, Biopsychology and Methods of Psychology, Technische Universität Dresden, Dresden, Germany
| | - Veit Roessner
- Eating Disorder Treatment and Research Center, Department of Child and Adolescent Psychiatry, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Michael N Smolka
- Department of Psychiatry and Neuroimaging, Technische Universität Dresden, Dresden, Germany
| | - Stefan Ehrlich
- Division of Psychological and Social Medicine and Developmental Neuroscience, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany.,Eating Disorder Treatment and Research Center, Department of Child and Adolescent Psychiatry, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
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20
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Schultz CC, Wagner G, de la Cruz F, Berger S, Reichenbach JR, Sauer H, Bär KJ. Evidence for alterations of cortical folding in anorexia nervosa. Eur Arch Psychiatry Clin Neurosci 2017; 267:41-49. [PMID: 26678081 DOI: 10.1007/s00406-015-0666-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 12/06/2015] [Indexed: 12/13/2022]
Abstract
Anorexia nervosa (AN) is highly heritable, and the perspective on the etiology of AN has changed from a behavioral to a neurobiological and neurodevelopmental view. However, cortical folding as an important marker for deviations in brain development has yet rarely been explored in AN. Hence, in order to determine potential cortical folding alterations, we investigated fine-grained cortical folding in a cohort of 26 patients with AN, of whom 6 patients were recovered regarding their weight at the time point of MRI measurement. MRI-derived cortical folding was computed and compared between patients and healthy controls at about 150,000 points per hemisphere using a surface-based technique (FreeSurfer). Patients with AN exhibited highly significant increased cortical folding in a right dorsolateral prefrontal cortex region (DLPFC). Furthermore, a statistical trend in the same direction was found in the right visual cortex. We did not find a correlation of local cortical folding and current symptoms of the disease. In conclusion, our analyses provide first evidence that altered DLPFC cortical folding plays a role in the etiology of AN. The absence of correlations with clinical parameters implicates a relatively independence of cortical folding alterations from the current symptomatology and might thus be regarded as a trait characteristic of the disease potentially related to other neurobiological features of AN.
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Affiliation(s)
- C Christoph Schultz
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Philosophenweg 3, 07740, Jena, Germany.
| | - Gerd Wagner
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Philosophenweg 3, 07740, Jena, Germany.,Psychiatric Brain & Body Research Group Jena, Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany
| | - Feliberto de la Cruz
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Philosophenweg 3, 07740, Jena, Germany.,Psychiatric Brain & Body Research Group Jena, Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany
| | - Sandy Berger
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Philosophenweg 3, 07740, Jena, Germany.,Psychiatric Brain & Body Research Group Jena, Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany
| | - Jürgen R Reichenbach
- Medical Physics Group, Institute for Diagnostic and Interventional Radiology, Jena University Hospital, Jena, Germany
| | - Heinrich Sauer
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Philosophenweg 3, 07740, Jena, Germany
| | - Karl J Bär
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Philosophenweg 3, 07740, Jena, Germany.,Psychiatric Brain & Body Research Group Jena, Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany
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21
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Scaife JC, Godier LR, Reinecke A, Harmer CJ, Park RJ. Differential activation of the frontal pole to high vs low calorie foods: The neural basis of food preference in Anorexia Nervosa? Psychiatry Res 2016; 258:44-53. [PMID: 27866012 PMCID: PMC5146322 DOI: 10.1016/j.pscychresns.2016.10.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 10/17/2016] [Accepted: 10/18/2016] [Indexed: 11/26/2022]
Abstract
Neuroimaging studies in anorexia nervosa (AN) suggest that altered food reward processing may result from dysfunction in both limbic reward and cortical control centers of the brain. This fMRI study aimed to index the neural correlates of food reward in a subsample of individuals with restrictive AN: twelve currently ill, fourteen recovered individuals and sixteen healthy controls. Participants were shown pictures of high and low-calorie foods and asked to evaluate how much they wanted to eat each one following a four hour fast. Whole-brain task-activated analysis was followed by psychophysiological interaction analysis (PPI) of the amygdala and caudate. In the AN group, we observed a differential pattern of activation in the lateral frontal pole: increasing following presentation of high-calorie stimuli and decreasing in during presentation of low-calorie food pictures, the opposite of which was seen in the healthy control (HC) group. In addition, decreased activation to food pictures was observed in somatosensory regions in the AN group. PPI analyses suggested hypo-connectivity in reward pathways, and between the caudate and both somatosensory and visual processing regions in the AN group. No significant between-group differences were observed between the recovered group and the currently ill and healthy controls in the PPI analysis. Taken together, these findings further our understanding of the neural processes which may underpin the avoidance of high-calorie foods in those with AN and might exacerbate the development of compulsive weight-loss behavior, despite emaciation.
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Affiliation(s)
- Jessica C Scaife
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK.
| | - Lauren R Godier
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK
| | - Andrea Reinecke
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK
| | - Catherine J Harmer
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK
| | - Rebecca J Park
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK
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22
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Sultson H, van Meer F, Sanders N, van Elburg AA, Danner UN, Hoek HW, Adan RAH, Smeets PAM. Associations between neural correlates of visual stimulus processing and set-shifting in ill and recovered women with anorexia nervosa. Psychiatry Res Neuroimaging 2016; 255:35-42. [PMID: 27518327 DOI: 10.1016/j.pscychresns.2016.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 04/27/2016] [Accepted: 07/07/2016] [Indexed: 11/18/2022]
Abstract
Women ill with anorexia nervosa (AN) have been shown to exhibit altered cognitive functioning, particularly poor set-shifting (SS). In this study, we investigated whether brain activation in frontal and parietal regions during visual stimulus processing correlates with SS ability. Women currently ill with AN (AN; N=14), recovered women (REC; N=14) and healthy controls (HC; N=15), viewed alternating blocks of food and non-food pictures during functional magnetic resonance imaging (fMRI). The Berg's Card Sorting Task was completed outside the scanner to measure SS. A priori regions of interest (ROIs) were defined in frontal and parietal regions. The activation during visual stimulus processing in several ROIs correlated positively with poor SS ability in REC, particularly in the left dorsal anterior cingulate cortex (dACC). The correlations with poor SS ability were opposite in AN patients, particularly in the right dACC. These findings underscore that addressing heightened levels of cognitive control associated with higher frontal activation could reduce cognitive inflexibility in recovered women. In AN, greater activation in frontal and parietal regions might be necessary to perform at normal levels during various tasks. Thus, weight restoration could be necessary for AN patients prior to addressing cognitive inflexibility.
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Affiliation(s)
- Hedvig Sultson
- Image Sciences Institute, University Medical Center Utrecht, Heidelberglaan 100, Q02.4.45, 3584 CX Utrecht, The Netherlands
| | - Floor van Meer
- Image Sciences Institute, University Medical Center Utrecht, Heidelberglaan 100, Q02.4.45, 3584 CX Utrecht, The Netherlands
| | - Nicole Sanders
- Altrecht Eating Disorders Rintveld, Altrecht Mental Health Institute, Zeist, The Netherlands; Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Annemarie A van Elburg
- Altrecht Eating Disorders Rintveld, Altrecht Mental Health Institute, Zeist, The Netherlands; Faculty of Social Sciences, Utrecht University, Utrecht, The Netherlands
| | - Unna N Danner
- Altrecht Eating Disorders Rintveld, Altrecht Mental Health Institute, Zeist, The Netherlands
| | - Hans W Hoek
- Altrecht Eating Disorders Rintveld, Altrecht Mental Health Institute, Zeist, The Netherlands; Parnassia Psychiatric Institute, The Hague, The Netherlands; Department of Psychiatry, University Medical Center Groningen, Groningen, The Netherlands
| | - Roger A H Adan
- Altrecht Eating Disorders Rintveld, Altrecht Mental Health Institute, Zeist, The Netherlands; Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Paul A M Smeets
- Image Sciences Institute, University Medical Center Utrecht, Heidelberglaan 100, Q02.4.45, 3584 CX Utrecht, The Netherlands; Division of Human Nutrition, Wageningen University & Research Center, Wageningen, The Netherlands.
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23
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Esposito R, Cieri F, di Giannantonio M, Tartaro A. The role of body image and self-perception in anorexia nervosa: the neuroimaging perspective. J Neuropsychol 2016; 12:41-52. [PMID: 27220759 DOI: 10.1111/jnp.12106] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 04/19/2016] [Indexed: 11/30/2022]
Abstract
Anorexia nervosa is a severe psychiatric illness characterized by intense fear of gaining weight, relentless pursuit of thinness, deep concerns about food and a pervasive disturbance of body image. Functional magnetic resonance imaging tries to shed light on the neurobiological underpinnings of anorexia nervosa. This review aims to evaluate the empirical neuroimaging literature about self-perception in anorexia nervosa. This narrative review summarizes a number of task-based and resting-state functional magnetic resonance imaging studies in anorexia nervosa about body image and self-perception. The articles listed in references were searched using electronic databases (PubMed and Google Scholar) from 1990 to February 2016 using specific key words. All studies were reviewed with regard to their quality and eligibility for the review. Differences in brain activity were observed using body image perception and body size estimation tasks showing significant modifications in activity of specific brain areas (extrastriate body area, fusiform body area, inferior parietal lobule). Recent studies highlighted the role of emotions and self-perception in anorexia nervosa and their neural substrate involving resting-state networks and particularly frontal and posterior midline cortical structures within default mode network and insula. These findings open new horizons to understand the neural substrate of anorexia nervosa.
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Affiliation(s)
- Roberto Esposito
- Department of Neuroscience, Imaging and Clinical Science, University "G. d'Annunzio" Chieti-Pescara, Chieti, Italy
| | - Filippo Cieri
- Department of Neuroscience, Imaging and Clinical Science, University "G. d'Annunzio" Chieti-Pescara, Chieti, Italy
| | - Massimo di Giannantonio
- Department of Neuroscience, Imaging and Clinical Science, University "G. d'Annunzio" Chieti-Pescara, Chieti, Italy
| | - Armando Tartaro
- Department of Neuroscience, Imaging and Clinical Science, University "G. d'Annunzio" Chieti-Pescara, Chieti, Italy
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24
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Chen J, Papies EK, Barsalou LW. A core eating network and its modulations underlie diverse eating phenomena. Brain Cogn 2016; 110:20-42. [PMID: 27156016 DOI: 10.1016/j.bandc.2016.04.004] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 01/03/2016] [Accepted: 04/15/2016] [Indexed: 12/20/2022]
Abstract
We propose that a core eating network and its modulations account for much of what is currently known about the neural activity underlying a wide range of eating phenomena in humans (excluding homeostasis and related phenomena). The core eating network is closely adapted from a network that Kaye, Fudge, and Paulus (2009) proposed to explain the neurocircuitry of eating, including a ventral reward pathway and a dorsal control pathway. In a review across multiple literatures that focuses on experiments using functional Magnetic Resonance Imaging (fMRI), we first show that neural responses to food cues, such as food pictures, utilize the same core eating network as eating. Consistent with the theoretical perspective of grounded cognition, food cues activate eating simulations that produce reward predictions about a perceived food and potentially motivate its consumption. Reviewing additional literatures, we then illustrate how various factors modulate the core eating network, increasing and/or decreasing activity in subsets of its neural areas. These modulating factors include food significance (palatability, hunger), body mass index (BMI, overweight/obesity), eating disorders (anorexia nervosa, bulimia nervosa, binge eating), and various eating goals (losing weight, hedonic pleasure, healthy living). By viewing all these phenomena as modulating a core eating network, it becomes possible to understand how they are related to one another within this common theoretical framework. Finally, we discuss future directions for better establishing the core eating network, its modulations, and their implications for behavior.
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Affiliation(s)
- Jing Chen
- Department of Psychology, Emory University, United States
| | - Esther K Papies
- Institute of Neuroscience and Psychology, University of Glasgow, UK; School of Psychology, University of Glasgow, UK
| | - Lawrence W Barsalou
- Institute of Neuroscience and Psychology, University of Glasgow, UK; School of Psychology, University of Glasgow, UK.
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25
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Van Autreve S, De. Baene W, Baeken C, van Heeringen K, Vancayseele N, Vervaet M. Differential Neural Correlates of Set-Shifting in the Bingeing-Purging and Restrictive Subtypes of Anorexia Nervosa: An fMRI Study. EUROPEAN EATING DISORDERS REVIEW 2016; 24:277-85. [PMID: 26856396 DOI: 10.1002/erv.2437] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 11/05/2015] [Accepted: 01/09/2016] [Indexed: 11/07/2022]
Affiliation(s)
- Sara Van Autreve
- Department of Psychiatry and Medical Psychology, Faculty of Medicine and Health Sciences; Ghent University; Belgium
| | - Wouter De. Baene
- Department of Experimental Psychology, Faculty of Psychology and Educational Sciences; Ghent University; Belgium
- Department of Cognitive Neuropsychology; Tilburg University; The Netherlands
| | - Chris Baeken
- Department of Psychiatry and Medical Psychology, Faculty of Medicine and Health Sciences; Ghent University; Belgium
| | - Kees van Heeringen
- Department of Psychiatry and Medical Psychology, Faculty of Medicine and Health Sciences; Ghent University; Belgium
| | - Nikita Vancayseele
- Department of Psychiatry and Medical Psychology, Faculty of Medicine and Health Sciences; Ghent University; Belgium
| | - Myriam Vervaet
- Department of Psychiatry and Medical Psychology, Faculty of Medicine and Health Sciences; Ghent University; Belgium
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26
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Biomarkers of Eating Disorders Using Support Vector Machine Analysis of Structural Neuroimaging Data: Preliminary Results. Behav Neurol 2015; 2015:924814. [PMID: 26648660 PMCID: PMC4663371 DOI: 10.1155/2015/924814] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 09/18/2015] [Accepted: 09/28/2015] [Indexed: 11/18/2022] Open
Abstract
Presently, there are no valid biomarkers to identify individuals with eating disorders (ED). The aim of this work was to assess the feasibility of a machine learning method for extracting reliable neuroimaging features allowing individual categorization of patients with ED. Support Vector Machine (SVM) technique, combined with a pattern recognition method, was employed utilizing structural magnetic resonance images. Seventeen females with ED (six with diagnosis of anorexia nervosa and 11 with bulimia nervosa) were compared against 17 body mass index-matched healthy controls (HC). Machine learning allowed individual diagnosis of ED versus HC with an Accuracy ≥ 0.80. Voxel-based pattern recognition analysis demonstrated that voxels influencing the classification Accuracy involved the occipital cortex, the posterior cerebellar lobule, precuneus, sensorimotor/premotor cortices, and the medial prefrontal cortex, all critical regions known to be strongly involved in the pathophysiological mechanisms of ED. Although these findings should be considered preliminary given the small size investigated, SVM analysis highlights the role of well-known brain regions as possible biomarkers to distinguish ED from HC at an individual level, thus encouraging the translational implementation of this new multivariate approach in the clinical practice.
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27
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Sauvaget A, Trojak B, Bulteau S, Jiménez-Murcia S, Fernández-Aranda F, Wolz I, Menchón JM, Achab S, Vanelle JM, Grall-Bronnec M. Transcranial direct current stimulation (tDCS) in behavioral and food addiction: a systematic review of efficacy, technical, and methodological issues. Front Neurosci 2015; 9:349. [PMID: 26500478 PMCID: PMC4598576 DOI: 10.3389/fnins.2015.00349] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 09/14/2015] [Indexed: 01/29/2023] Open
Abstract
Objectives: Behavioral addictions (BA) are complex disorders for which pharmacological and psychotherapeutic treatments have shown their limits. Non-invasive brain stimulation, among which transcranial direct current stimulation (tDCS), has opened up new perspectives in addiction treatment. The purpose of this work is to conduct a critical and systematic review of tDCS efficacy, and of technical and methodological considerations in the field of BA. Methods: A bibliographic search has been conducted on the Medline and ScienceDirect databases until December 2014, based on the following selection criteria: clinical studies on tDCS and BA (namely eating disorders, compulsive buying, Internet addiction, pathological gambling, sexual addiction, sports addiction, video games addiction). Study selection, data analysis, and reporting were conducted according to the PRISMA guidelines. Results: Out of 402 potential articles, seven studies were selected. So far focusing essentially on abnormal eating, these studies suggest that tDCS (right prefrontal anode/left prefrontal cathode) reduces food craving induced by visual stimuli. Conclusions: Despite methodological and technical differences between studies, the results are promising. So far, only few studies of tDCS in BA have been conducted. New research is recommended on the use of tDCS in BA, other than eating disorders.
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Affiliation(s)
- Anne Sauvaget
- Addictology and Liaison Psychiatry Department, Nantes University Hospital Nantes, France ; Clinical Investigation Unit 18-BALANCED "BehaviorAL AddictioNs and ComplEx Mood Disorders", University Hospital of Nantes Nantes, France ; Department of Psychiatry, University Hospital of Bellvitge-IDIBELL Barcelona, Spain
| | - Benoît Trojak
- Department of Psychiatry and Addictology, University Hospital of Dijon Dijon, France ; Behavioral Addictions Program, NANT New Addictions New Treatments, Addiction Division, Department of Mental Health and Psychiatry, University Hospital of Geneva Geneva, Switzerland
| | - Samuel Bulteau
- Addictology and Liaison Psychiatry Department, Nantes University Hospital Nantes, France ; Clinical Investigation Unit 18-BALANCED "BehaviorAL AddictioNs and ComplEx Mood Disorders", University Hospital of Nantes Nantes, France
| | - Susana Jiménez-Murcia
- Department of Psychiatry, University Hospital of Bellvitge-IDIBELL Barcelona, Spain ; CIBER Fisiopatología Obesidad y Nutrición, Instituto de Salud Carlos III Barcelona, Spain
| | - Fernando Fernández-Aranda
- Department of Psychiatry, University Hospital of Bellvitge-IDIBELL Barcelona, Spain ; CIBER Fisiopatología Obesidad y Nutrición, Instituto de Salud Carlos III Barcelona, Spain
| | - Ines Wolz
- Department of Psychiatry, University Hospital of Bellvitge-IDIBELL Barcelona, Spain ; CIBER Fisiopatología Obesidad y Nutrición, Instituto de Salud Carlos III Barcelona, Spain
| | - José M Menchón
- Department of Psychiatry, University Hospital of Bellvitge-IDIBELL Barcelona, Spain ; CIBER Salud Mental, Instituto de Salud Carlos III Barcelona, Spain
| | - Sophia Achab
- Behavioral Addictions Program, NANT New Addictions New Treatments, Addiction Division, Department of Mental Health and Psychiatry, University Hospital of Geneva Geneva, Switzerland
| | - Jean-Marie Vanelle
- Addictology and Liaison Psychiatry Department, Nantes University Hospital Nantes, France ; Clinical Investigation Unit 18-BALANCED "BehaviorAL AddictioNs and ComplEx Mood Disorders", University Hospital of Nantes Nantes, France
| | - Marie Grall-Bronnec
- Addictology and Liaison Psychiatry Department, Nantes University Hospital Nantes, France ; Clinical Investigation Unit 18-BALANCED "BehaviorAL AddictioNs and ComplEx Mood Disorders", University Hospital of Nantes Nantes, France ; EA 4275 "Biostatistics, Clinical Research and Subjective Measures in Health Sciences", University of Nantes Nantes, France
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28
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Favaro A, Tenconi E, Degortes D, Manara R, Santonastaso P. Gyrification brain abnormalities as predictors of outcome in anorexia nervosa. Hum Brain Mapp 2015; 36:5113-22. [PMID: 26374960 DOI: 10.1002/hbm.22998] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 08/03/2015] [Accepted: 09/08/2015] [Indexed: 12/15/2022] Open
Abstract
Gyrification brain abnormalities are considered a marker of early deviations from normal developmental trajectories and a putative predictor of poor outcome in psychiatric disorders. The aim of this study was to explore cortical folding morphology in patients with anorexia nervosa (AN). A MRI brain study was conducted on 38 patients with AN, 20 fully recovered patients, and 38 healthy women. Local gyrification was measured with procedures implemented in FreeSurfer. Vertex-wise comparisons were carried out to compare: (1) AN patients and healthy women; (2) patients with a full remission at a 3-year longitudinal follow-up assessment and patients who did not recover. AN patients exhibited significantly lower gyrification when compared with healthy controls. Patients with a poor 3-year outcome had significantly lower baseline gyrification when compared to both healthy women and patients with full recovery at follow-up, even after controlling for the effects of duration of illness and gray matter volume. No significant correlation has been found between gyrification, body mass index, amount of weight loss, onset age, and duration of illness. Brain gyrification significantly predicted outcome at follow-up even after controlling for the effects of duration of illness and other clinical prognostic factors. Although the role of starvation in determining our findings cannot be excluded, our study showed that brain gyrification might be a predictor of outcome in AN. Further studies are needed to understand if brain gyrification abnormalities are indices of early neurodevelopmental alterations, the consequence of starvation, or the interaction between both factors.
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Affiliation(s)
- Angela Favaro
- Department of Neurosciences, University of Padova, Italy.,Centro Neuroscienze Cognitive, University of Padova, Italy.,Neuroradiology Unit, IRCSS San Camillo, Venice, Italy
| | - Elena Tenconi
- Department of Neurosciences, University of Padova, Italy.,Centro Neuroscienze Cognitive, University of Padova, Italy
| | | | - Renzo Manara
- Department of Medicine, University of Salerno, Italy.,Neuroradiology Unit, IRCSS San Camillo, Venice, Italy
| | - Paolo Santonastaso
- Department of Neurosciences, University of Padova, Italy.,Centro Neuroscienze Cognitive, University of Padova, Italy
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29
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Bär KJ, de la Cruz F, Berger S, Schultz CC, Wagner G. Structural and functional differences in the cingulate cortex relate to disease severity in anorexia nervosa. J Psychiatry Neurosci 2015; 40:269-79. [PMID: 25825813 PMCID: PMC4478060 DOI: 10.1503/jpn.140193] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The dysfunction of specific brain areas might account for the distortion of body image in patients with anorexia nervosa. The present study was designed to reveal brain regions that are abnormal in structure and function in patients with this disorder. We hypothesized, based on brain areas of altered activity in patients with anorexia nervosa and regions involved in pain processing, an interrelation of structural aberrations in the frontoparietal-cingulate network and aberrant functional activation during thermal pain processing in patients with the disorder. METHODS We determined pain thresholds outside the MRI scanner in patients with anorexia nervosa and matched healthy controls. Thereafter, thermal pain stimuli were applied during fMRI imaging. Structural analyses with high-resolution structural T1-weighted volumes were performed using voxel-based morphometry and a surface-based approach. RESULTS Twenty-six patients and 26 controls participated in our study, and owing to technical difficulties, 15 participants in each group were included in our fMRI analysis. Structural analyses revealed significantly decreased grey matter volume and cortical thickness in the frontoparietal-cingulate network in patients with anorexia nervosa. We detected an increased blood oxygen level-dependent signal in patients during the painful 45 °C condition in the midcingulate and posterior cingulate cortex, which positively correlated with increased pain thresholds. Decreased grey matter and cortical thickness correlated negatively with pain thresholds, symptom severity and illness duration, but not with body mass index. LIMITATIONS The lack of a specific quantification of body image distortion is a limitation of our study. CONCLUSION This study provides further evidence for confined structural and functional brain abnormalities in patients with anorexia nervosa in brain regions that are involved in perception and integration of bodily stimuli. The association of structural and functional deviations with thermal thresholds as well as with clinical characteristics might indicate a common neuronal origin.
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Affiliation(s)
- Karl-Jürgen Bär
- Correspondence to: K.-J. Bär, Department of Psychiatry and Psychotherapy, University Hospital, Philosophenweg 3, 07743 Jena, Germany;
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30
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Cleary DR, Ozpinar A, Raslan AM, Ko AL. Deep brain stimulation for psychiatric disorders: where we are now. Neurosurg Focus 2015; 38:E2. [DOI: 10.3171/2015.3.focus1546] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Fossil records showing trephination in the Stone Age provide evidence that humans have sought to influence the mind through physical means since before the historical record. Attempts to treat psychiatric disease via neurosurgical means in the 20th century provided some intriguing initial results. However, the indiscriminate application of these treatments, lack of rigorous evaluation of the results, and the side effects of ablative, irreversible procedures resulted in a backlash against brain surgery for psychiatric disorders that continues to this day. With the advent of psychotropic medications, interest in invasive procedures for organic brain disease waned.
Diagnosis and classification of psychiatric diseases has improved, due to a better understanding of psychiatric patho-physiology and the development of disease and treatment biomarkers. Meanwhile, a significant percentage of patients remain refractory to multiple modes of treatment, and psychiatric disease remains the number one cause of disability in the world. These data, along with the safe and efficacious application of deep brain stimulation (DBS) for movement disorders, in principle a reversible process, is rekindling interest in the surgical treatment of psychiatric disorders with stimulation of deep brain sites involved in emotional and behavioral circuitry.
This review presents a brief history of psychosurgery and summarizes the development of DBS for psychiatric disease, reviewing the available evidence for the current application of DBS for disorders of the mind.
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Affiliation(s)
- Daniel R. Cleary
- 1Department of Neurology, Yale Medical School, New Haven, Connecticut
| | - Alp Ozpinar
- 2Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Ahmed M. Raslan
- 2Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Andrew L. Ko
- 3Department of Neurological Surgery, University of Washington, Seattle, Washington
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31
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Hayes DJ, Lipsman N, Chen DQ, Woodside DB, Davis KD, Lozano AM, Hodaie M. Subcallosal Cingulate Connectivity in Anorexia Nervosa Patients Differs From Healthy Controls: A Multi-tensor Tractography Study. Brain Stimul 2015; 8:758-68. [PMID: 26073966 DOI: 10.1016/j.brs.2015.03.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 03/18/2015] [Accepted: 03/21/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Anorexia nervosa is characterized by extreme low body weight and alterations in affective processing. The subcallosal cingulate regulates affect through wide-spread white matter connections and is implicated in the pathophysiology of anorexia nervosa. OBJECTIVES We examined whether those with treatment refractory anorexia nervosa undergoing deep brain stimulation (DBS) of the subcallosal white matter (SCC) show: (1) altered anatomical SCC connectivity compared to healthy controls, (2) white matter microstructural changes, and (3) microstructural changes associated with clinically-measured affect. METHODS Diffusion magnetic resonance imaging (dMRI) and deterministic multi-tensor tractography were used to compare anatomical connectivity and microstructure in SCC-associated white matter tracts. Eight women with treatment-refractory anorexia nervosa were compared to 8 age- and sex-matched healthy controls. Anorexia nervosa patients also completed affect-related clinical assessments presurgically and 12 months post-surgery. RESULTS (1) Higher (e.g., left parieto-occipital cortices) and lower (e.g., thalamus) connectivity in those with anorexia nervosa compared to controls. (2) Decreases in fractional anisotropy, and alterations in axial and radial diffusivities, in the left fornix crus, anterior limb of the internal capsule (ALIC), right anterior cingulum and left inferior fronto-occipital fasciculus. (3) Correlations between dMRI metrics and clinical assessments, such as low pre-surgical left fornix and right ALIC fractional anisotropy being related to post-DBS improvements in quality-of-life and depressive symptoms, respectively. CONCLUSIONS We identified widely-distributed differences in SCC connectivity in anorexia nervosa patients consistent with heterogenous clinical disruptions, although these results should be considered with caution given the low number of subjects. Future studies should further explore the use of affect-related connectivity and behavioral assessments to assist with DBS target selection and treatment outcome.
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Affiliation(s)
- Dave J Hayes
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Toronto Western Research Institute, Division of Brain, Imaging and Behaviour - Systems Neuroscience, University Health Network, Toronto, Ontario M5T 2S8, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada
| | - Nir Lipsman
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Toronto Western Research Institute, Division of Brain, Imaging and Behaviour - Systems Neuroscience, University Health Network, Toronto, Ontario M5T 2S8, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada
| | - David Q Chen
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Toronto Western Research Institute, Division of Brain, Imaging and Behaviour - Systems Neuroscience, University Health Network, Toronto, Ontario M5T 2S8, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada
| | - D Blake Woodside
- Department of Psychiatry, University of Toronto, Toronto General Hospital, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Karen D Davis
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Toronto Western Research Institute, Division of Brain, Imaging and Behaviour - Systems Neuroscience, University Health Network, Toronto, Ontario M5T 2S8, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada
| | - Andres M Lozano
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Toronto Western Research Institute, Division of Brain, Imaging and Behaviour - Systems Neuroscience, University Health Network, Toronto, Ontario M5T 2S8, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada
| | - Mojgan Hodaie
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Toronto Western Research Institute, Division of Brain, Imaging and Behaviour - Systems Neuroscience, University Health Network, Toronto, Ontario M5T 2S8, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada.
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32
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Mahr F, Farahmand P, Bixler EO, Domen RE, Moser EM, Nadeem T, Levine RL, Halmi KA. A national survey of eating disorder training. Int J Eat Disord 2015; 48:443-5. [PMID: 25047025 DOI: 10.1002/eat.22335] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 06/14/2014] [Accepted: 07/06/2014] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Eating disorders (EDs) result in the highest mortality rate of all psychiatric disorders, and in the United States, approximately one in twenty females suffers from an eating disorder. However, training provided within residency programs to address the needs of these patients is sparse. The objective of this study was to conduct a national survey that assesses the amount of EDs training for trainees across five ACGME accredited specialties: internal medicine, pediatrics, family medicine, psychiatry, and child and adolescent psychiatry. The results of the survey will be used to develop strategies to improve eating disorder education among residents. METHOD Eight hundred eighty training coordinators were contacted using information available on the ACGME website and asked to complete the survey. RESULTS Of the 637 responding programs, 514 did not offer any scheduled or elective rotations for EDs. Of the 123 programs offering rotations, only 42 offered a formal, scheduled rotation. Child and adolescent psychiatry offered the most clinical experiences, and pediatric programs offered the greatest number of didactic hours on EDs. DISCUSSION Training in EDs is limited. Simulated patient encounters, massive open online courses, web-based curricula, dedicated rotations and clinical experiences, didactic curricula, and brief-training programs may help to improve eating disorder diagnostic and treatment skills among trainees.
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Affiliation(s)
- Fauzia Mahr
- Penn State Milton S. Hershey Medical Center 500 university drive Hershey PA, PO BOX 850 H073, 17033, USA
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Khedr E, El Fetoh N, El Bieh E, Ali A, Karim A. Altered cortical excitability in anorexia nervosa. Neurophysiol Clin 2014; 44:291-9. [DOI: 10.1016/j.neucli.2014.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 08/04/2014] [Accepted: 08/05/2014] [Indexed: 10/24/2022] Open
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Abstract
OBJECTIVES Anorexia nervosa (AN), a disorder of unknown etiology, has the highest mortality rate of any psychiatric disorder. Drawing the brain metabolic pattern of AN may help to target the core biological and psychological features of the disorder and to perfect the diagnosis and recovery criteria. In this study, we used 18F-FDG PET to show brain metabolic network for AN. METHODS Glucose metabolism in 6 AN patients and 12 age-matched healthy controls was studied using 18F-FDG PET. SPM2 was used to compare brain metabolism in AN patients with that in healthy controls. Four of 6 AN patients took deep brain stimulation (DBS) targeted in nucleus accumbens (NAcc). About 3 to 6 months after the surgery, the 4 AN patients took another 18F-FDG PET scan to assess the change in brain glucose metabolism. RESULTS The SPM (statistical parametric mapping ) analysis showed hypermetabolism in the frontal lobe (bilateral, BA10, BA11, BA47), the limbic lobe (bilateral, hippocampus, and amygdala), lentiform nucleus (bilateral), left insula (BA13), and left subcallosal gyrus (BA25). It also showed hypometabolism in the parietal lobe (bilateral, BA7, BA40). The hypermetabolism in frontal lobe, hippocampus, and lentiform nucleus decreased after NAcc-DBS. CONCLUSIONS The changes in brain glucose metabolism illustrated the brain metabolic pattern in AN patients. Furthermore, the pattern can be modulated by NAcc-DBS, which confirmed specificity of the pattern. The regions with altered metabolism could interconnect to form a network and integrate information related to appetite. Our study may provide information for targeting the potential candidate brain regions for understanding the pathophysiology of AN and assessing the effects of existing and future treatment approaches.
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Katayama H, Kohmura K, Tanaka S, Imaeda M, Kawano N, Noda Y, Nishioka K, Ando M, Aleksic B, Iidaka T, Ozaki N. Social insecurity in relation to orbitofrontal activity in patients with eating disorders: a near-infrared spectroscopy study. BMC Psychiatry 2014; 14:173. [PMID: 24924100 PMCID: PMC4067083 DOI: 10.1186/1471-244x-14-173] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 06/05/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Functional neuroimaging techniques are widely used to elucidate changes in brain activity, and various questionnaires are used to investigate psychopathological features in patients with eating disorders (ED). It is well known that social skills and interpersonal difficulties are strongly associated with the psychopathology of patients with ED. However, few studies have examined the association between brain activity and social relationships in patients with ED, particularly in patients with extremely low body weight. METHODS In this study, 22-channel near-infrared spectroscopy was used to quantify regional hemodynamic changes during a letter fluency task (LFT) in 20 female patients with ED with a mean body mass index of 14.0 kg/m(2) and 31 female controls (CTLs). Symptoms were assessed using the Eating Disorder Inventory-2 and Beck Depression Inventory. We hypothesized that frontal activity in patients with ED would be lower than in CTLs and would show different correlations with psychopathological features compared with CTLs. RESULTS The LFT performance and score on the social insecurity subscale of the Eating Disorder Inventory-2 were significantly higher in the ED group than in the CTL group. The mean change in oxygenated hemoglobin (oxy-Hb) in bilateral frontal regions during the LFT was significantly smaller in the ED group than in the CTL group. Social insecurity score was positively correlated with the concentration of oxy-Hb in the bilateral orbitofrontal cortex in the ED group but not in the CTL group. CONCLUSIONS These results suggest that activity of the orbitofrontal cortex is associated with social insecurity and disturbed in patients with ED. Therefore, disturbed orbitofrontal cortex activity may underlie the lack of insight and social isolation that is characteristic of patients with ED.
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Affiliation(s)
- Hiroto Katayama
- Department of Psychiatry, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi-ken 466-8550, Japan
| | - Kunihiro Kohmura
- Department of Psychiatry, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi-ken 466-8550, Japan
| | - Satoshi Tanaka
- Department of Psychiatry, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi-ken 466-8550, Japan
| | - Miho Imaeda
- Department of Psychiatry, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi-ken 466-8550, Japan
| | - Naoko Kawano
- Department of Psychiatry, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi-ken 466-8550, Japan
| | - Yukihiro Noda
- Division of Clinical Science and Neuropsychopharmacology, Graduate School of Pharmacy, Meijo University, 150 Yagotoyama, Tenpaku-ku, Nagoya, Aichi-ken 468-8503, Japan
- The Academic Frontier Project for Private Universities, Comparative Cognitive Science Institutes, Meijo University, 1-501 Shiogamaguchi, Tenpaku-ku, Nagoya, Aichi-ken 468-8502, Japan
| | - Kazuo Nishioka
- Department of Psychiatry, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi-ken 466-8550, Japan
| | - Masahiko Ando
- Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Aichi-ken 466-8550, Japan
| | - Branko Aleksic
- Department of Psychiatry, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi-ken 466-8550, Japan
| | - Tetsuya Iidaka
- Department of Psychiatry, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi-ken 466-8550, Japan
| | - Norio Ozaki
- Department of Psychiatry, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi-ken 466-8550, Japan
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McFadden KL, Tregellas JR, Shott ME, Frank GK. Reduced salience and default mode network activity in women with anorexia nervosa. J Psychiatry Neurosci 2014; 39:178-88. [PMID: 24280181 PMCID: PMC3997603 DOI: 10.1503/jpn.130046] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The neurobiology of anorexia nervosa is poorly understood. Neuronal networks contributing to action selection, self-regulation and interoception could contribute to pathologic eating and body perception in people with anorexia nervosa. We tested the hypothesis that the salience network (SN) and default mode network (DMN) would show decreased intrinsic activity in women with anorexia nervosa and those who had recovered from the disease compared to controls. The basal ganglia (BGN) and sensorimotor networks (SMN) were also investigated. METHODS Between January 2008 and January 2012, women with restricting-type anorexia nervosa, women who recovered from the disease and healthy control women completed functional magnetic resonance imaging during a conditioned stimulus task. Network activity was studied using independent component analysis. RESULTS We studied 20 women with anorexia nervosa, 24 recovered women and 24 controls. Salience network activity in the anterior cingulate cortex was reduced in women with anorexia nervosa (p = 0.030; all results false-discovery rate- corrected) and recovered women (p = 0.039) compared to controls. Default mode network activity in the precuneus was reduced in women with anorexia compared to controls (p = 0.023). Sensorimotor network activity in the supplementary motor area (SMA; p = 0.008), and the left (p = 0.028) and right (p = 0.002) postcentral gyrus was reduced in women with anorexia compared to controls; SMN activity in the SMA (p = 0.019) and the right postcentral gyrus (p = 0.008) was reduced in women with anorexia compared to recovered women. There were no group differences in the BGN. LIMITATIONS Differences between patient and control populations (e.g., depression, anxiety, medication) are potential confounds, but were included as covariates. CONCLUSION Reduced SN activity in women with anorexia nervosa and recovered women could be a trait-related biomarker or illness remnant, altering the drive to approach food. The alterations in the DMN and SMN observed only in women with anorexia nervosa suggest state-dependent abnormalities that could be related to altered interoception and body image in these women when they are underweight but that remit following recovery.
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Affiliation(s)
| | | | | | - Guido K.W. Frank
- Correspondence to: G.K.W. Frank, Departments of Psychiatry and Neuroscience, The Children’s Hospital, Gary Pavilion A036/B-130, 13123 East 16th Ave., Aurora CO 80045;
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Evaluating the potential of deep brain stimulation for treatment-resistant anorexia nervosa. HANDBOOK OF CLINICAL NEUROLOGY 2014; 116:271-6. [PMID: 24112901 DOI: 10.1016/b978-0-444-53497-2.00022-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/17/2023]
Abstract
Anorexia nervosa is a chronic and debilitating psychiatric disorder associated with one of the highest mortality rates of any psychiatric condition. Despite advances in neuroimaging, genetics, pharmacology, and psychosocial interventions in the last half-century, little progress has been made in altering the natural history of the condition or its outcomes. Evidence is now emerging that the condition is, at least in part, maintained by dysfunctional activity in key neuroanatomic circuits subserving illness-maintaining symptoms. Abnormal reward processing, compulsive hyperactivity, chronic anxiety, and depression, all suggest that anorexia nervosa shares much in common with other conditions, such as major depression and obsessive-compulsive disorder, for which surgical therapy with deep brain stimulation (DBS) has been tried, with promising results. As a result, the use of DBS in treatment-resistant anorexia nervosa should be evaluated in carefully designed, early-phase feasibility trials.
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Dazzi F, Di Leone FG. The diagnostic classification of eating disorders: current situation, possible alternatives and future perspectives. Eat Weight Disord 2014; 19:11-9. [PMID: 24104389 DOI: 10.1007/s40519-013-0076-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 09/23/2013] [Indexed: 11/30/2022] Open
Abstract
The current nosography of eating disorders (ED) has various limitations in terms of validity and accuracy. The changes adopted in the DSM-5 limit some of the current problems, such as excessive prevalence of ED not otherwise specified (EDNOS) and the lack of longitudinal stability, but are unlikely to adequately capture the clinical complexity of ED. Many authors suggest the need for a thorough review of the current nosography to support evidence-based classification. In this paper, we discuss the validity of the current diagnostic categories and their possible reorganization. Furthermore, we review the main empirical models of classification and the diagnostic approach from a personality perspective, with particular attention to research and to the prognostic and therapeutic implications.
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Affiliation(s)
- F Dazzi
- Marconi University, Rome, Italy,
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Rocks T, Pelly F, Wilkinson P. Nutrition therapy during initiation of refeeding in underweight children and adolescent inpatients with anorexia nervosa: a systematic review of the evidence. J Acad Nutr Diet 2014; 114:897-907. [PMID: 24512952 DOI: 10.1016/j.jand.2013.11.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 11/20/2013] [Indexed: 01/08/2023]
Abstract
Restoration of weight and nutritional rehabilitation are recognized as fundamental steps in the therapeutic treatment of children and adolescent inpatients with anorexia nervosa (AN). However, current recommendations on initial energy requirements for this population are inconsistent, with a clear lack of empirical evidence. Thus, the aim of our study was to systematically review, assess, and summarize the available evidence on the effect of differing nutrition therapies prescribed during refeeding on weight restoration in hospitalized children and adolescents (aged 19 years and younger) with diagnosed AN. Searches were conducted in Scopus, Web of Science, Global Health (CABI), PubMed, and the Cochrane database for articles published in English up to May 2012, and complemented by a search of the reference lists of key publications. Seven observational studies investigating a total of 403 inpatients satisfied the inclusion criteria. The range of prescribed energy intakes varied from 1,000 kcal to >1,900 kcal/day with a progressive increase during the course of hospitalization. It appeared that additional tube feeding increased the maximum energy intake and led to greater interim or discharge weight; however, this was also associated with a higher incidence of adverse effects. Overall, the level of available evidence was poor, and therefore consensus on the most effective and safe treatment for weight restoration in inpatient children and adolescents with AN is not currently feasible. Further research on refeeding methods is crucial to establish the best practice approach to treatment of this population.
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Pászthy B, Törzsök-Sonnevend M. [Pathogenesis of anorexia nervosa. Neurobiological risk factors and possible endophenotypes]. Orv Hetil 2014; 155:124-31. [PMID: 24440724 DOI: 10.1556/oh.2014.29812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Anorexia nervosa is a serious, chronical state of illness which often starts in childhood or adolescence and has serious consequences on the quality of life. This review focuses on the heterogenity of the disease with emphasis on special diagnostic implications in case of childhood onset. Research findings of the last decade showed that genetic and neurobiological vulnerabilities are at least as potent risk factors as psychological, family constellations and sociocultural preferences. The heritability of eating disorders levels those of diseases predominantly influenced by biological factors. The authors give a summary of the most investigated neurobiologic and neurocognitive factors which could be the fundaments of a biological vulnerablilty. To date, no common risk factor could be identified, but some existing adversities can clearly be related to distinct subgroups with the disorder. The concept of endo- and subphenotypes leads to more specific and more efficient methods of therapy in other somatic and psychiatric diseases.
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Affiliation(s)
- Bea Pászthy
- Semmelweis Egyetem, Általános Orvostudományi Kar I. Gyermekgyógyászati Klinika, Gyermek- és Ifjúságpszichiátriai Osztály Budapest Bókay J. u. 53. 1086
| | - Mária Törzsök-Sonnevend
- Semmelweis Egyetem, Általános Orvostudományi Kar I. Gyermekgyógyászati Klinika, Gyermek- és Ifjúságpszichiátriai Osztály Budapest Bókay J. u. 53. 1086
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Bainbridge K, Brown A. rTMS as a Treatment for Anorexia Nervosa. Brain Stimul 2014; 7:149-50. [DOI: 10.1016/j.brs.2013.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 09/20/2013] [Accepted: 09/24/2013] [Indexed: 11/26/2022] Open
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Hartmann AS, Thomas JJ, Wilson AC, Wilhelm S. Insight impairment in body image disorders: delusionality and overvalued ideas in anorexia nervosa versus body dysmorphic disorder. Psychiatry Res 2013; 210:1129-35. [PMID: 23992792 DOI: 10.1016/j.psychres.2013.08.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 07/01/2013] [Accepted: 08/08/2013] [Indexed: 01/12/2023]
Abstract
The two body image disorders anorexia nervosa (AN) and body dysmorphic disorder (BDD) share many similarities. Delusionality in BDD has recently gained increased attention, as the new DSM-5 criteria for BDD include an insight specifier. However, delusionalilty in AN has rarely been examined. We evaluated the delusionality of appearance-related beliefs in AN (n=19) vs. BDD (n=22) via structured interview. Participants also completed measures of disorder-specific psychopathology and body image. Compared to those with AN, individuals with BDD exhibited significantly greater delusionality on a dimensional scale (p=0.0014, d=1.07), and were more likely to meet dichotomous criteria for delusional beliefs (p=0.021, V=0.36). In AN, delusionality was associated specifically with shape concerns and drive for thinness; in BDD, delusionality was related to the severity of BDD symptoms (all p<0.05). Delusionality of appearance beliefs is present in individuals with AN, but is less pronounced than in BDD. Nevertheless, as high delusionality might predict poor treatment outcome in AN, treatment strategies that were originally developed to address delusionality in BDD might be modified for AN.
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Affiliation(s)
- Andrea S Hartmann
- Institute of Psychology, Department of Human Sciences, University of Osnabrück, Knollstrasse 15, 49069 Osnabrück, Germany; Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
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Karas PJ, Mikell CB, Christian E, Liker MA, Sheth SA. Deep brain stimulation: a mechanistic and clinical update. Neurosurg Focus 2013; 35:E1. [DOI: 10.3171/2013.9.focus13383] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Deep brain stimulation (DBS), the practice of placing electrodes deep into the brain to stimulate subcortical structures with electrical current, has been increasing as a neurosurgical procedure over the past 15 years. Originally a treatment for essential tremor, DBS is now used and under investigation across a wide spectrum of neurological and psychiatric disorders. In addition to applying electrical stimulation for clinical symptomatic relief, the electrodes implanted can also be used to record local electrical activity in the brain, making DBS a useful research tool. Human single-neuron recordings and local field potentials are now often recorded intraoperatively as electrodes are implanted. Thus, the increasing scope of DBS clinical applications is being matched by an increase in investigational use, leading to a rapidly evolving understanding of cortical and subcortical neurocircuitry. In this review, the authors discuss recent innovations in the clinical use of DBS, both in approved indications as well as in indications under investigation. Deep brain stimulation as an investigational tool is also reviewed, paying special attention to evolving models of basal ganglia and cortical function in health and disease. Finally, the authors look to the future across several indications, highlighting gaps in knowledge and possible future directions of DBS treatment.
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Affiliation(s)
- Patrick J. Karas
- 1Department of Neurosurgery, The Neurological Institute, Columbia University Medical Center, New York, New York; and
| | - Charles B. Mikell
- 1Department of Neurosurgery, The Neurological Institute, Columbia University Medical Center, New York, New York; and
| | - Eisha Christian
- 2Department of Neurosurgery, Keck Hospital of the University of Southern California, Los Angeles, California
| | - Mark A. Liker
- 2Department of Neurosurgery, Keck Hospital of the University of Southern California, Los Angeles, California
| | - Sameer A. Sheth
- 1Department of Neurosurgery, The Neurological Institute, Columbia University Medical Center, New York, New York; and
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Oudijn MS, Storosum JG, Nelis E, Denys D. Is deep brain stimulation a treatment option for anorexia nervosa? BMC Psychiatry 2013; 13:277. [PMID: 24175936 PMCID: PMC4229382 DOI: 10.1186/1471-244x-13-277] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 10/22/2013] [Indexed: 11/10/2022] Open
Abstract
Anorexia nervosa (AN) is a severe psychiatric disorder with high rates of morbidity, comorbidity and mortality, which in a subset of patients (21%) takes on a chronic course. Since an evidence based treatment for AN is scarce, it is crucial to investigate new treatment options, preferably focused on influencing the underlying neurobiological mechanisms of AN. The objective of the present paper was to review the evidence for possible neurobiological correlates of AN, and to hypothesize about potential targets for Deep brain stimulation (DBS) as a treatment for chronic, therapy-refractory AN. One avenue for exploring new treatment options based on the neurobiological correlates of AN, is the search for symptomatologic and neurobiologic parallels between AN and other compulsivity- or reward-related disorders. As in other compulsive disorders, the fronto-striatal circuitry, in particular the insula, the ventral striatum (VS) and the prefrontal, orbitofrontal, temporal, parietal and anterior cingulate cortices, are likely to be implicated in the neuropathogenesis of AN. In this paper we will review the few available cases in which DBS has been performed in patients with AN (either as primary diagnosis or as comorbid condition). Given the overlap in symptomatology and neurocircuitry between reward-related disorders such as obsessive compulsive disorder (OCD) and AN, and the established efficacy of accumbal DBS in OCD, we hypothesize that DBS of the nucleus accumbens (NAc) and other areas associated with reward, e.g. the anterior cingulated cortex (ACC), might be an effective treatment for patients with chronic, treatment refractory AN, providing not only weight restoration, but also significant and sustained improvement in AN core symptoms and associated comorbidities and complications. Possible targets for DBS in AN are the ACC, the ventral anterior limb of the capsula interna (vALIC) and the VS. We suggest conducting larger efficacy studies that also explore the functional effects of DBS in AN.
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Affiliation(s)
- Marloes S Oudijn
- Department of Psychiatry, Academic Medical Centre, University of Amsterdam, Meibergdreef 5, 1105, AZ Amsterdam, the Netherlands
| | - Jitschak G Storosum
- Department of Psychiatry, Academic Medical Centre, University of Amsterdam, Meibergdreef 5, 1105, AZ Amsterdam, the Netherlands
| | - Elise Nelis
- Department of Psychiatry, Academic Medical Centre, University of Amsterdam, Meibergdreef 5, 1105, AZ Amsterdam, the Netherlands
| | - Damiaan Denys
- Department of Psychiatry, Academic Medical Centre, University of Amsterdam, Meibergdreef 5, 1105, AZ Amsterdam, the Netherlands.
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McClelland J, Bozhilova N, Nestler S, Campbell IC, Jacob S, Johnson-Sabine E, Schmidt U. Improvements in Symptoms Following Neuronavigated Repetitive Transcranial Magnetic Stimulation (rTMS) in Severe and Enduring Anorexia Nervosa: Findings from two Case Studies. EUROPEAN EATING DISORDERS REVIEW 2013; 21:500-6. [DOI: 10.1002/erv.2266] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Clinical pharmacology of eating and not eating. Curr Opin Pharmacol 2013; 14:1-5. [PMID: 24565004 DOI: 10.1016/j.coph.2013.09.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 09/12/2013] [Accepted: 09/20/2013] [Indexed: 11/20/2022]
Abstract
FDA approval of Belviq and Qsymia seems to suggest that novel pharmacological targets to modulate human abnormal eating behaviours are still to be identified. However, a renewed translational approach opens new avenues on eating disorders and female vulnerability, highlighting the role of our reward pathway in obesity and binge eating and leading to potential novel targets. Nevertheless, the 'food addiction' hypothesis is still causing much scientific debate. In this context the interest in the modulation of ghrelin pathway is still very high although, so far, only ghrelin agonism has confirmed its therapeutic potential in cachectic patients. Unfortunately, ghrelin modulation does not offer a therapeutic option for Anorexia Nervosa, where novel promising pharmacological treatments are still to be uncovered.
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Abstract
The eating disorders anorexia nervosa (AN) and bulimia nervosa (BN) are severe psychiatric disorders with high mortality. Our knowledge about the neurobiology of eating disorders is very limited, and the question remains whether alterations in brain structure or function in eating disorders are state related, remnants of the illness or premorbid traits. The brain reward system is a relatively well-characterized brain circuitry that plays a central role in the drive to eat and individuals with current or past eating disorders showed alterations in those pathways compared to controls. Here we propose that structural and functional alterations in the insula and frontal cortex, including orbitofrontal and cingulate regions, areas that contribute to reward and anxiety processing, could predispose to developing an eating disorder and that adaptive changes in those circuits in response to malnutrition or repeated binge eating and purging could further promote illness behavior, hinder recovery and contribute to relapse.
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Affiliation(s)
- Guido K W Frank
- Departments of Psychiatry and Neuroscience, University of Colorado Anschutz Medical Campus, School of Medicine, Children's Hospital Colorado, Aurora, CO 80045, USA.
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48
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McClelland J, Bozhilova N, Campbell I, Schmidt U. A systematic review of the effects of neuromodulation on eating and body weight: evidence from human and animal studies. EUROPEAN EATING DISORDERS REVIEW 2013; 21:436-55. [PMID: 24155246 DOI: 10.1002/erv.2256] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Revised: 08/17/2013] [Indexed: 01/17/2023]
Abstract
BACKGROUND Eating disorders (ED) are chronic and sometimes deadly illnesses. Existing treatments have limited proven efficacy, especially in the case of adults with anorexia nervosa (AN). Emerging neural models of ED provide a rationale for more targeted, brain-directed interventions. AIMS This systematic review has examined the effects of neuromodulation techniques on eating behaviours and body weight and assessed their potential for therapeutic use in ED. METHOD All articles in PubMed, PsychInfo and Web of Knowledge were considered and screened against a priori inclusion/exclusion criteria. The effects of repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation, vagus nerve stimulation (VNS) and deep brain stimulation (DBS) were examined across studies in ED samples, other psychiatric and neurological disorders, and animal models. RESULTS Sixty studies were identified. There is evidence for ED symptom reduction following rTMS and DBS in both AN and bulimia nervosa. Findings from studies of other psychiatric and neurological disorders and from animal studies demonstrate that increases in food intake and body weight can be achieved following DBS and that VNS has potential value as a means of controlling eating and inducing weight loss. CONCLUSIONS Neuromodulation tools have potential for reducing ED symptomatology and related behaviours, and for altering food intake and body weight. In response to such findings, and emerging neural models of ED, treatment approaches are highly unlikely to remain 'brainless'. More research is required to evaluate the potential of neuromodulation procedures for improving long-term outcomes in ED.
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Affiliation(s)
- Jessica McClelland
- Section of Eating Disorders, Institute of Psychiatry, King's College London, London, UK
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Oltra-Cucarella J, Espert R, Rojo L, Jacas C, Guillén V, Moreno S. Neuropsychological Impairments in Anorexia Nervosa: A Spanish Sample Pilot Study. APPLIED NEUROPSYCHOLOGY-ADULT 2013; 21:161-75. [DOI: 10.1080/09084282.2013.782030] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
| | - Raul Espert
- a Unit of Neuropsychology , Hospital Clínico Universitario , Valencia , Spain
| | - Luís Rojo
- b Unit of Infant/Juvenile Psychiatry and Eating Disorders , Hospital Universitari y Politècnic La Fe , Valencia , Spain
| | - Carlos Jacas
- c Unit of Neuropsychology, Department of Psychiatry , Hospital Universitario Vall d'Hebrón , Barcelona , Spain
| | - Verónica Guillén
- d Faculty of Psychology , University of Valencia, and Unit of Eating Disorders, PREVI Center of Psychology , Valencia , Spain
| | - Sergio Moreno
- a Unit of Neuropsychology , Hospital Clínico Universitario , Valencia , Spain
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Lipsman N, Woodside DB, Giacobbe P, Lozano AM. Neurosurgical Treatment of Anorexia Nervosa: Review of the Literature from Leucotomy to Deep Brain Stimulation. EUROPEAN EATING DISORDERS REVIEW 2013; 21:428-35. [DOI: 10.1002/erv.2246] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 06/29/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Nir Lipsman
- Division of Neurosurgery, University Health Network; University of Toronto; Toronto ON Canada
| | - D. Blake Woodside
- Department of Psychiatry, University Health Network; University of Toronto; Toronto ON Canada
| | - Peter Giacobbe
- Department of Psychiatry, University Health Network; University of Toronto; Toronto ON Canada
| | - Andres M. Lozano
- Division of Neurosurgery, University Health Network; University of Toronto; Toronto ON Canada
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