Neuroendocrinology and brain imaging of reward in eating disorders: A possible key to the treatment of anorexia nervosa and bulimia nervosa

Assessing biomarkers of remission in female patients with anorexia nervosa (REMANO): a protocol for a prospective cohort study with a nested case-control study using clinical, neurocognitive, biological, genetic, epigenetic and neuroimaging markers in a French specialised inpatient unit

BACKGROUND

Anorexia nervosa (AN) is a severe psychiatric disorder associated with frequent relapses and variability in treatment responses. Previous literature suggested that such variability is influenced by premorbid vulnerabilities such as abnormalities of the reward system. Several factors may indicate these vulnerabilities, such as neurocognitive markers (tendency to favour delayed reward, poor cognitive flexibility, abnormal decision process), genetic and epigenetic markers, biological and hormonal markers, and physiological markers.The present study will aim to identify markers that can predict body mass index (BMI) stability 6 months after discharge. The secondary aim of this study will be focused on characterising the biological, genetic, epigenetic and neurocognitive markers of remission in AN.

METHODS AND ANALYSIS

One hundred and twenty-five (n=125) female adult inpatients diagnosed with AN will be recruited and evaluated at three different times: at the beginning of hospitalisation, when discharged and 6 months later. Depending on the BMI at the third visit, patients will be split into two groups: stable remission (BMI≥18.5 kg/m²) or unstable remission (BMI<18.5 kg/m²). One hundred (n=100) volunteers will be included as healthy controls.Each visit will consist in self-reported inventories (measuring depression, anxiety, suicidal thoughts and feelings, eating disorders symptoms, exercise addiction and the presence of comorbidities), neurocognitive tasks (Delay Discounting Task, Trail-Making Test, Brixton Test and Slip-of-action Task), the collection of blood samples, the repeated collection of blood samples around a standard meal and MRI scans at rest and while resolving a delay discounting task.Analyses will mainly consist in comparing patients stabilised 6 months later and patients who relapsed during these 6 months.

ETHICS AND DISSEMINATION

Investigators will ask all participants to give written informed consent prior to participation, and all data will be recorded anonymously. The study will be conducted according to ethics recommendations from the Helsinki declaration (World Medical Association, 2013). It was registered on clinicaltrials.gov on 25 August 2020 as 'Remission Factors in Anorexia Nervosa (REMANO)', with the identifier NCT04560517 (for more details, see https://clinicaltrials.gov/ct2/show/record/NCT04560517). The present article is based on the latest protocol version from 29 November 2019. The sponsor, Institut National de la Santé Et de la Recherche Médicale (INSERM, https://www.inserm.fr/), is an academic institution responsible for the monitoring of the study, with an audit planned on a yearly basis.The results will be published after final analysis in the form of scientific articles in peer-reviewed journals and may be presented at national and international conferences.

TRIAL REGISTRATION NUMBER

clinicaltrials.govNCT04560517.

Testing associations between assessments of cognitive flexibility and eating disorder symptoms in adolescent bulimia nervosa

OBJECTIVE

Cognitive rigidity, or difficulty adapting to changing demands, is commonly observed in anorexia nervosa. Less is known, however, about cognitive flexibility (CF) in bulimia nervosa (BN) and, particularly, adolescence. Clarifying this relation and best assessment practices may guide informed clinical decision-making. The current study compared how two measures of CF (i.e., Wisconsin Card Sort Task [WCST] and Trail Making Task [TMT]) relate to BN symptoms among adolescents.

METHODS

Data from a subsample (n = 78) of adolescents with BN were analyzed. Linear and hurdle regressions were used to compare the effects of WCST perseverative errors and TMT performance on Eating Disorder Examination Global Scores, objective binge episodes, and self-induced vomiting episodes (SVEs) at baseline and end-of-treatment (EOT).

RESULTS

Neither CF measure associated with baseline BN symptoms. TMT performance positively associated with the likelihood of engaging in SVEs at EOT (𝛽 = 0.47, p = 0.01, 95% confidence interval [CI] = [0.11-0.84]) and, among adolescents who endorsed ≥1 SVE at EOT, WCST perseverative errors (𝛽 = 0.05, p = 0.005, 95% CI = [0.01-0.08]) positively associated with SVE frequency at EOT.

DISCUSSION

The overall lack of associations between CF and outcomes suggests that cognitive rigidity may not be as relevant to the clinical profile of adolescent BN as for anorexia nervosa. In the few significant associations that emerged, the WCST and TMT uniquely predicted the severity of vomiting at EOT in this sample. Given the lack of CF deficits, future work should aim to test the role of other executive functions (e.g., impulsivity), in addition to CF, to determine which deficits are present in adolescent BN and may predict outcomes.

PUBLIC SIGNIFICANCE

Patients with eating disorders often have difficulties thinking flexibly, which may interfere with their recovery. We tested two ways of measuring flexible thinking in adolescents with BN. Overall, flexible thinking was not associated with symptom-level outcomes. However, less flexible thinking at the start of treatment predicted self-induced vomiting at EOT. If findings are replicable, then assessing and addressing flexible thinking could improve outcomes for adolescents with BN.

Dynamic Amygdala Nuclei Alterations in Relation to Weight Status in Anorexia Nervosa Are Mediated by Leptin

OBJECTIVE

The amygdaloid complex is a subcortical limbic group of distinct nuclei. In a previous patient-control study, differential amygdala nuclei alterations were found in acute anorexia nervosa (AN); rostral-medial nuclei involved in fear and reward processing were substantially reduced in volume and associated with hypoleptinemia, a key neuroendocrine characteristic of AN. Here, longitudinal amygdala nuclei alterations in AN were investigated in relation to weight status and their associations with leptin levels.

METHOD

T1-weighted structural magnetic resonance imaging scans were longitudinally processed with FreeSurfer. Amygdala nuclei volumes in young female patients with acute AN before and after short-term weight restoration (n = 110, >14% body mass index increase over 3 months) and female participants with a history of AN (n = 79, long-term [mean 5 years] weight recovered) were compared with female healthy control participants (n = 271) using linear mixed effects models.

RESULTS

Rostral-medially clustered amygdala nuclei volumes, accessory basal, cortical, medial nuclei, and corticoamygdaloid transition, increased during short-term weight restoration (Cohen's d range 0.18-0.30). However, volumetric normalization across nuclei was heterogeneous. Right cortical, medial nuclei, bilateral corticoamygdaloid transitions, and anterior amygdaloid areas were only partially normalized following short-term weight restoration. Right anterior amygdaloid area remained reduced after long-term weight recovery compared with control participants (d = 0.36). Leptin increase, accompanying short-term weight restoration, mediated the effect of weight gain on volumetric increase in left corticoamygdaloid transition and bilateral medial nuclei.

CONCLUSION

Rostral-medially clustered amygdala nuclei show pronounced volumetric increase but incomplete normalization in AN during and after short-term weight restoration. Leptin increase may be relevant for the recovery of specific amygdala nuclei in addition to nutritional rehabilitation, indicating links between amygdala substructure and leptin dynamics of potential pathophysiological and clinical relevance in AN.

PLAIN LANGUAGE SUMMARY

The amygdala plays a critical role in processing fearful and rewarding stimuli, and alterations in the amygdala are associated with anorexia nervosa. In this study, the authors measured amygdala nuclei volumes in female patients with acute anorexia nervosa undergoing weight-restoration treatment (n = 110), long-term weight-recovered individuals with anorexia (n = 79), and healthy control participants (n = 271). Structural magnetic resonance imaging revealed that volumes of specific nuclei, clustered in the rostral-medial amygdala, were substantially reduced in acute anorexia nervosa and only partially normalized following weight restoration treatment. Residual reductions in volume persisted even after long-term weight-recovery, compared to healthy control participants. Short-term weight restoration was associated with increases in the neurohormone leptin, and increasing leptin levels were found to mediate the positive impact of weight gain on increased amygdala volume over the treatment course.

DIVERSITY & INCLUSION STATEMENT

We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way. One or more of the authors of this paper received support from a program designed to increase minority representation in science. We actively worked to promote sex and gender balance in our author group. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. While citing references scientifically relevant for this work, we also actively worked to promote sex and gender balance in our reference list. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work.

Dynamic Changes in Local Brain Connectivity and Activity: A Longitudinal Study in Adolescent Anorexia Nervosa

BACKGROUND

Resting-state functional connectivity analysis has been used to study disruptions in neural circuitries underlying eating disorder symptoms. Research has shown resting-state functional connectivity to be altered during the acute phase of anorexia nervosa (AN), but little is known about the biological mechanisms underlying neural changes associated with weight restoration. The goal of the current study was to investigate longitudinal changes in regional homogeneity (ReHo) among neighboring voxels, degree centrality (DC) (a voxelwise whole brain correlation coefficient), voxel-mirrored homotopic connectivity (VMHC) (measuring the synchronization between hemispheres), and the fractional amplitude of low-frequency fluctuations associated with weight gain during AN treatment.

METHODS

Resting-state functional connectivity data were acquired and analyzed from a sample of 174 female volunteers: 87 underweight patients with AN that were scanned before treatment and again after at least 12% body mass index increase, as well as 87 age-matched healthy control participants.

RESULTS

Longitudinal changes in ReHo, DC, VMHC, and the fractional amplitude of low-frequency fluctuations were observed in most regions identified to differ between patients with AN before treatment and healthy control participants. However, the degree of normalization varied for each parameter, ranging from 9% of all clusters in DC to 66% in VMHC. Longitudinal changes in ReHo and VMHC showed a linear association weight gain.

CONCLUSIONS

Resting-state functional magnetic resonance imaging measures, including ReHo, DC, VMHC, and the fractional amplitude of low-frequency fluctuations, show varying degrees of recovery after short-term weight restoration. Although only some of these changes were related to weight gain, our results provide an overall positive message, suggesting that weight restoration is associated with changes in functional brain measures that point toward normalization.

iPSC-derived models for anorexia nervosa research

Anorexia nervosa (AN) is a complex neuropsychiatric disorder with genetic and epigenetic components that results in reduced food intake combined with alterations in the reward-processing network. While studies of patient cohorts and mouse models have uncovered genes and epigenetic changes associated with the disease, neuronal networks and brain areas preferentially activated and metabolic changes associated with reduced food intake, the underlying molecular and cellular mechanisms remain unknown. The use of both 2D in vitro cultures and 3D models, namely organoids and spheroids, derived from either human embryonic stem cells (ESCs) or induced pluripotent stem cells (iPSCs), would allow identification of cell type-specific changes associated with AN and comorbid diseases, to study preferential connections between brain areas and organs, and the development of therapeutic strategies.

An advance in novel intelligent sensory technologies: From an implicit-tracking perspective of food perception

Food sensory evaluation mainly includes explicit and implicit measurement methods. Implicit measures of consumer perception are gaining significant attention in food sensory and consumer science as they provide effective, subconscious, objective analysis. A wide range of advanced technologies are now available for analyzing physiological and psychological responses, including facial analysis technology, neuroimaging technology, autonomic nervous system technology, and behavioral pattern measurement. However, researchers in the food field often lack systematic knowledge of these multidisciplinary technologies and struggle with interpreting their results. In order to bridge this gap, this review systematically describes the principles and highlights the applications in food sensory and consumer science of facial analysis technologies such as eye tracking, facial electromyography, and automatic facial expression analysis, as well as neuroimaging technologies like electroencephalography, magnetoencephalography, functional magnetic resonance imaging, and functional near-infrared spectroscopy. Furthermore, we critically compare and discuss these advanced implicit techniques in the context of food sensory research and then accordingly propose prospects. Ultimately, we conclude that implicit measures should be complemented by traditional explicit measures to capture responses beyond preference. Facial analysis technologies offer a more objective reflection of sensory perception and attitudes toward food, whereas neuroimaging techniques provide valuable insight into the implicit physiological responses during food consumption. To enhance the interpretability and generalizability of implicit measurement results, further sensory studies are needed. Looking ahead, the combination of different methodological techniques in real-life situations holds promise for consumer sensory science in the field of food research.

Exploring YouTube Videos About Anorexia Nervosa on the Basis of Reliability, Popularity, and Contributions of Healthcare Professionals: A Cross-Sectional Study

BACKGROUND

 Anorexia nervosa, an eating disorder, is characterized by a distorted body image, intense fear of gaining weight, and self-imposed starvation. The aim of this study is to analyze type of information as well as its quality and reliability on YouTube about anorexia nervosa.  Methodology: A cross-sectional observational study was conducted on 59 Youtube videos using anorexia nervosa-related keywords in June 2023. The characteristics of the YouTube videos, such as the language of the information, the time of upload, and the qualifications of the uploaders, were recorded. The content and quality of 59 videos were assessed using the Global Quality Score (GQS) and reliability grading systems.

RESULTS

The videos accumulated a total of 256,602 likes, 5,644 dislikes, and 17,761 comments. Treatment-related content accounted for 81.36% of the videos, while descriptions of symptoms comprised 79.66%. Doctors contributed to 18.6% of the total uploads, making them the second-largest group of uploaders after the 'Other' category. The median reliability score for doctors is 4, the same as the hospital healthcare organization. This indicates that the perceived reliability of doctors as a source of information is as high as that of hospital healthcare organizations.

CONCLUSIONS

In conclusion, this study highlights the importance of critically evaluating information on anorexia nervosa videos on YouTube. Despite variations in popularity, the overall quality and reliability remained consistent. Doctors were perceived as reliable sources of information, comparable to hospital healthcare organizations. Ensuring accurate and trustworthy content is crucial for supporting those affected by anorexia nervosa and promoting reliable information to the public.

Explicating the role of amygdala substructure alterations in the link between hypoleptinemia and rumination in anorexia nervosa

OBJECTIVE

The amygdaloid complex plays a pivotal role in emotion processing and has been associated with rumination transdiagnostically. In anorexia nervosa (AN), we previously observed differential reductions of amygdala nuclei volumes (rostral-medial cluster substantially affected) and, in another study, elevated food-/weight-related rumination. Both amygdala volumes and rumination frequency correlated with characteristically suppressed leptin levels in AN. Thus, we hypothesized that amygdala nuclei alterations might be associated with AN-related rumination and potentially mediate the leptin-rumination relationship in AN.

METHODS

Rumination (food-/weight-related) was assessed using ecological momentary assessment for a 14-day period. We employed frequentist and Bayesian linear mixed effects models in females with AN (n = 51, 12-29 years, majority admitted to inpatient treatment) and age-matched healthy females (n = 51) to investigate associations between rostral-medial amygdala nuclei volume alterations (accessory basal, cortical, medial nuclei, corticoamygdaloid transitions) and rumination. We analyzed mediation effects using multi-level structural equation models.

RESULTS

Reduced right accessory basal and cortical nuclei volumes predicted more frequent weight-related rumination in AN; both nuclei fully mediated the effect of leptin on weight-related rumination. In contrast, we found robust evidence for the absence of amygdala nuclei volume effects on rumination in healthy females.

CONCLUSION

This study provides first evidence for the relevance of specific amygdala substructure reductions regarding cognitive symptom severity in AN and points toward novel mechanistic insight into the relationship between hypoleptinemia and rumination, which might involve the amygdaloid complex. Our findings in AN may have important clinical value with respect to understanding the beneficial neuropsychiatric effects of leptin (treatment) in AN and potentially other psychiatric conditions such as depression.

Connectome-based prediction of eating disorder-associated symptomatology

BACKGROUND

Despite increasing knowledge on the neuroimaging patterns of eating disorder (ED) symptoms in non-clinical populations, studies using whole-brain machine learning to identify connectome-based neuromarkers of ED symptomatology are absent. This study examined the association of connectivity within and between large-scale functional networks with specific symptomatic behaviors and cognitions using connectome-based predictive modeling (CPM).

METHODS

CPM with ten-fold cross-validation was carried out to probe functional networks that were predictive of ED-associated symptomatology, including body image concerns, binge eating, and compensatory behaviors, within the discovery sample of 660 participants. The predictive ability of the identified networks was validated using an independent sample of 821 participants.

RESULTS

The connectivity predictive of body image concerns was identified within and between networks implicated in cognitive control (frontoparietal and medial frontal), reward sensitivity (subcortical), and visual perception (visual). Crucially, the set of connections in the positive network related to body image concerns identified in one sample was generalized to predict body image concerns in an independent sample, suggesting the replicability of this effect.

CONCLUSIONS

These findings point to the feasibility of using the functional connectome to predict ED symptomatology in the general population and provide the first evidence that functional interplay among distributed networks predicts body shape/weight concerns.

Neural effects of deep brain stimulation on reward and loss anticipation and food viewing in anorexia nervosa: a pilot study

BACKGROUND

Anorexia nervosa (AN) is a severe and life-threatening psychiatric disorder. Initial studies on deep brain stimulation (DBS) in severe, treatment-refractory AN have shown clinical effects. However, the working mechanisms of DBS in AN remain largely unknown. Here, we used a task-based functional MRI approach to understand the pathophysiology of AN.

METHODS

We performed functional MRI on four AN patients that participated in a pilot study on the efficacy, safety, and functional effects of DBS targeted at the ventral limb of the capsula interna (vALIC). The patients and six gender-matched healthy controls (HC) were investigated at three different time points. We used an adapted version of the monetary incentive delay task to probe generic reward processing in patients and controls, and a food-specific task in patients only.

RESULTS

At baseline, no significant differences for reward anticipation were found between AN and HC. Significant group (AN and HC) by time (pre- and post-DBS) interactions were found in the right precuneus, right putamen, right ventral and medial orbitofrontal cortex (mOFC). No significant interactions were found in the food viewing task, neither between the conditions high-calorie and low-calorie food images nor between the different time points. This could possibly be due to the small sample size and the lack of a control group.

CONCLUSION

The results showed a difference in the response of reward-related brain areas post-DBS. This supports the hypotheses that the reward circuitry is involved in the pathogenesis of AN and that DBS affects responsivity of reward-related brain areas. Trial registration Registered in the Netherlands Trial Register ( https://www.trialregister.nl/trial/3322 ): NL3322 (NTR3469).

Neuro-Vulnerability in Energy Metabolism Regulation: A Comprehensive Narrative Review

This comprehensive narrative review explores the concept of neuro-vulnerability in energy metabolism regulation and its implications for metabolic disorders. The review highlights the complex interactions among the neural, hormonal, and metabolic pathways involved in the regulation of energy metabolism. The key topics discussed include the role of organs, hormones, and neural circuits in maintaining metabolic balance. The review investigates the association between neuro-vulnerability and metabolic disorders, such as obesity, insulin resistance, and eating disorders, considering genetic, epigenetic, and environmental factors that influence neuro-vulnerability and subsequent metabolic dysregulation. Neuroendocrine interactions and the neural regulation of food intake and energy expenditure are examined, with a focus on the impact of neuro-vulnerability on appetite dysregulation and altered energy expenditure. The role of neuroinflammation in metabolic health and neuro-vulnerability is discussed, emphasizing the bidirectional relationship between metabolic dysregulation and neuroinflammatory processes. This review also evaluates the use of neuroimaging techniques in studying neuro-vulnerability and their potential applications in clinical settings. Furthermore, the association between neuro-vulnerability and eating disorders, as well as its contribution to obesity, is examined. Potential therapeutic interventions targeting neuro-vulnerability, including pharmacological treatments and lifestyle modifications, are reviewed. In conclusion, understanding the concept of neuro-vulnerability in energy metabolism regulation is crucial for addressing metabolic disorders. This review provides valuable insights into the underlying neurobiological mechanisms and their implications for metabolic health. Targeting neuro-vulnerability holds promise for developing innovative strategies in the prevention and treatment of metabolic disorders, ultimately improving metabolic health outcomes.

Potential biomarker of brain response to opioid antagonism in adolescents with eating disorders: a pilot study

Background

Eating Disorders (ED) affect up to 5% of youth and are associated with reward system alterations and compulsive behaviors. Naltrexone, an opioid antagonist, is used to treat ED behaviors such as binge eating and/or purging. The presumed mechanism of action is blockade of reward activation; however, not all patients respond, and the optimal dose is unknown. Developing a tool to detect objective drug response in the brain will facilitate drug development and therapeutic optimization. This pilot study evaluated neuroimaging as a pharmacodynamic biomarker of opioid antagonism in adolescents with ED.

Methods

Youth aged 13-21 with binge/purge ED completed functional magnetic resonance imaging (fMRI) pre- and post-oral naltrexone. fMRI detected blood oxygenation-level dependent (BOLD) signal at rest and during two reward probes (monetary incentive delay, MID, and passive food view, PFV) in predefined regions of interest associated with reward and inhibitory control. Effect sizes for Δ%BOLD (post-naltrexone vs. baseline) were estimated using linear mixed effects modeling.

Results

In 12 youth (16-21 years, 92% female), BOLD signal changes were detected following naltrexone in the nucleus accumbens during PFV (Δ%BOLD -0.08 ± 0.03; Cohen's d -1.06, p = 0.048) and anterior cingulate cortex during MID (Δ%BOLD 0.06 ± 0.03; Cohen's d 1.25, p = 0.086).

Conclusion

fMRI detected acute reward pathway modulation in this small sample of adolescents with binge/purge ED. If validated in future, larger trials, task-based Δ%BOLD detected by fMRI may serve as a pharmacodynamic biomarker of opioid antagonism to facilitate the development of novel therapeutics targeting the reward pathway, enable quantitative pharmacology trials, and inform drug dosing.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT04935931, NCT#04935931.

Food restriction and hyperactivity induce changes in corticolimbic brain dopamine and serotonin levels in female rats

Compelling data support altered dopamine (DA) and serotonin (5-HT) signaling in anorexia nervosa (AN). However, their exact role in the etiopathogenesis of AN has yet to be elucidated. Here, we evaluated the corticolimbic brain levels of DA and 5-HT in the induction and recovery phases of the activity-based anorexia (ABA) model of AN. We exposed female rats to the ABA paradigm and measured the levels of DA, 5-HT, the metabolites 3,4-dihydroxyphenylacetic acid (DOPAC), homovanillic acid (HVA), 5-hydroxyindoleacetic acid (5-HIAA), and the dopaminergic type 2 (D2) receptors density in feeding- and reward-implicated brain regions (i.e., cerebral cortex, Cx; prefrontal cortex, PFC; caudate putamen, CPu; nucleus accumbens, NAcc; amygdala, Amy; hypothalamus, Hyp; hippocampus, Hipp). DA levels were significantly increased in the Cx, PFC and NAcc, while 5-HT was significantly enhanced in the NAcc and Hipp of ABA rats. Following recovery, DA was still elevated in the NAcc, while 5-HT was increased in the Hyp of recovered ABA rats. DA and 5-HT turnover were impaired at both ABA induction and recovery. D2 receptors density was increased in the NAcc shell. These results provide further proof of the impairment of the dopaminergic and serotoninergic systems in the brain of ABA rats and support the knowledge of the involvement of these two important neurotransmitter systems in the development and progression of AN. Thus, providing new insights on the corticolimbic regions involved in the monoamine dysregulations in the ABA model of AN.

Norepinephrine system at the interface of attention and reward

Reward learning is key to survival for individuals. Attention plays an important role in the rapid recognition of reward cues and establishment of reward memories. Reward history reciprocally guides attention to reward stimuli. However, the neurological processes of the interplay between reward and attention remain largely elusive, due to the diversity of the neural substrates that participate in these two processes. In this review, we delineate the complex and differentiated locus coeruleus norepinephrine (LC-NE) system in relation to different behavioral and cognitive substrates of reward and attention. The LC receives reward related sensory, perceptual, and visceral inputs, releases NE, glutamate, dopamine and various neuropeptides, forms reward memories, drives attentional bias and selects behavioral strategies for reward. Preclinical and clinical studies have found that abnormalities in the LC-NE system are involved in a variety of psychiatric conditions marked by disturbed functions in reward and attention. Therefore, we propose that the LC-NE system is an important hub in the interplay between reward and attention as well as a critical therapeutic target for psychiatric disorders characterized by compromised functions in reward and attention.

Exploration of the relationships between clinical traits and functional connectivity based on surface morphology abnormalities in bulimia nervosa

BACKGROUND

Bulimia nervosa is a recurrent eating disorder with uncertain pathogenesis. Recently, there has been growing interest in using neuroimaging techniques to explore brain structural and functional alterations in bulimia nervosa, but the findings of previous studies have a great number of inconsistencies.

METHODS

Here, we collected anatomical and resting-state functional magnetic resonance imaging data from 43 bulimia nervosa patients and 34 matched healthy controls (HCs). We applied a surface-based morphology analysis to explore brain cortical morphology differences and a novel surface-based functional connectivity (FC) analysis to investigate functional abnormalities. Principal component analysis was performed to analyze the behavioral data of the participants. We further analyzed the relationships between abnormalities in cortical characteristics or FC and clinical features.

RESULTS

We observed increased greater sulcal depth in the right superior temporal gyrus (STG) and the right medial orbitofrontal cortex (mOFC) in bulimia nervosa patients than in the HCs. Additionally, the patients exhibited increased FC between the right STG and right ventral tegmental area but decreased function between the right mOFC and right putamen, which was significantly negatively correlated with the first principal component reflecting the severity of bulimia nervosa symptom.

CONCLUSIONS

Our findings provide evidence of neuroanatomical and functional abnormalities in bulimia nervosa patients. Moreover, the FC between the right mOFC and right putamen was associated with symptom severity of bulimia nervosa, which may be a neural marker and involved in the neuropathological mechanism of bulimia nervosa.

Network analysis of eating disorder symptoms in women in perimenopause and early postmenopause

OBJECTIVE

Eating disorders (EDs) are often stereotyped as disorders of adolescence and young adulthood; however, they can occur at any age. Prevalence of EDs at midlife are approximately 3.5% and specific symptoms at midlife can have prevalences as high as 29.3%. Studies also inconsistently suggest that EDs and related symptoms may be more prevalent in midlife aged women during perimenopause compared with midlife aged women at pre-menopause. To date few studies have examined the structure of and associations between ED symptoms in women specifically during perimenopause and early postmenopause. Thus, the purpose of the current study is to investigate the structure of ED symptoms specifically during perimenopause and early postmenopause.

METHODS

Participants included 36 participants (45-61 y old) in a larger clinical trial who completed the Eating Disorder Examination Questionnaire (EDE-Q) at a baseline study visit. Network analysis statistical models were used to examine the structure of and associations between ED symptoms assessed via the EDE-Q.

RESULTS

Shape dissatisfaction and weight dissatisfaction were the top 2 central symptoms in the network.

CONCLUSIONS

Results corroborate previous studies and indicate that, similar to young adult samples, dissatisfaction with body image is a core feature of ED pathology across the lifespan.

Gray matter volume and functional connectivity underlying binge eating in healthy children

PURPOSE

As a maladaptive disordered eating behavior, binge eating (BE) onset has been reported in children as young as eight years old and is linked with a range of negative psychological consequences. However, previous neuroimaging research of BE has mainly focused on adults in clinical conditions, and little is known about the potential neurostructural and neurofunctional bases of BE in healthy children.

METHODS

In this study, we examined these issues in 76 primary school students (mean age = 9.86 years) using voxel-based morphometry and resting-state functional connectivity (rsFC) approaches.

RESULTS

After controlling for age, sex, and total intracranial volume/head motion, we observed that higher levels of BE were correlated with greater gray matter volumes (GMV) in the left fusiform and right insula and weaker rsFC between the right insula and following three regions: right orbital frontal cortex, left cingulate gyrus, and left superior frontal gyrus. No significant associations were observed between BE and regional white matter volume. Significant sex differences were found only in the relationship between BE and GMV in the left fusiform. Furthermore, the GMV- and rsFC-based predictive models (a machine-learning method) achieved significant correlations between the actual and predicted BE values, demonstrating the robustness of our findings.

CONCLUSION

The present study provides novel evidence for the brain structural and functional substrates of children's BE, and further reveals that the weakened communication between core regions associated with negative affectivity, reward responsivity, and executive function is strongly related to dysregulated eating.

LEVEL OF EVIDENCE

Level V, descriptive study.

Brain reward response in adolescents and young adults with anorexia nervosa is moderated by changes in body weight and sweetness perception

OBJECTIVE

Anorexia nervosa (AN) is a severe psychiatric illness with complex etiology. Recently, we found elevated striatal brain response to sweet taste stimuli in adolescents and young adults with AN. Here, we tested the hypothesis that nutritional rehabilitation normalizes prediction error activation, a measure for dopamine-related reward circuit response, to salient caloric taste stimuli in AN.

METHODS

A total of 28 individuals with AN (age = 16 ± 2 years; body mass index [BMI] = 16 ± 1) who previously underwent brain imaging while performing a taste prediction error task using sucrose as salient caloric stimulus, participated in a second brain imaging scan (BMI = 18 ± 1) after intensive specialized eating disorder treatment (41 ± 15 days). A total of 31 healthy controls (age = 16 ± 3 years; BMI = 21 ± 2) were also studied on two occasions.

RESULTS

At baseline, individuals with AN demonstrated an elevated salience response in bilateral caudate head and nucleus accumbens, and right ventral striatum. At the second scan, elevated response was only found in the right nucleus accumbens. A moderator analysis indicated that greater increase in BMI and greater decrease in sweetness perception predicted lesser prediction error response at the second scan in AN.

CONCLUSION

Consistent with the previously reported monetary stimulus-response, elevated taste prediction error response in AN was largely absent after weight restoration. This study indicates that changes in BMI and sweet taste perception are independent moderators of change of brain salience response in adolescents and young adults with AN. The study points toward dynamic changes in the brain reward circuitry in AN and highlights the importance of nutrition and weight restoration in that process.

PUBLIC SIGNIFICANCE STATEMENT

AN is a severe psychiatric illness. Biological factors that integrate neurobiology and behavior could become important targets to improve treatment outcome. This study highlights the importance of weight normalization and taste perception the normalization of brain function, and food type or taste-specific interventions could help in the recovery process. Furthermore, the study suggests that food-related and nonfood-related reward processing adapts to illness state in AN.

The Fitter I Am, the Larger I Feel-The Vicious Circle of Physical Exercise in Anorexia Nervosa

Introduction: Body image distortion is a core symptom of anorexia nervosa (AN), embodying dissatisfaction and overvaluation of body appearance and weight. Body image distortion is an important factor in the maintenance of weight loss behaviours such as compulsive physical exercise. Conversely, physical exercise seems to have an aggravating effect on body image in patients with AN, but the evidence is still poor. The aim of this study was to examine the relationship between body image distortion and physical exercise in AN in order to understand whether physical exercise may play a specific role in body image distortion beyond psychopathological severity. Methods: Forty patients with AN and 21 healthy controls were tested for body image distortion and different proxies of physical exercise. Univariate correlations tested the relationship between body image distortion and physical exercise in AN and control groups. Then, to experimentally assess the effect of exercise on body image distortion, participants were invited to rate their body image before and after a standardised effort test. Results: In the AN group, a correlation was found between physical activity and body image distortion (p < 0.01), which was still significant after controlling for psychopathological severity. No correlation was found in healthy controls. After a standardised effort, patients with AN had higher increases in body image distortion than healthy controls (almost 4 kg/m2 vs. 0.8 kg/m2) (p < 0.01). Discussion: Physical exercise may contribute to the distortion of body image in anorexia nervosa and explain the paradoxical augmentation of unhealthy exercise despite ongoing weight loss.

Neural correlates associated with processing food stimuli in anorexia nervosa and bulimia nervosa: an activation likelihood estimation meta-analysis of fMRI studies

PURPOSE

Various neurobiological models have utilised symptom categories to explore the underlying neural correlates in both anorexia nervosa (AN) and bulimia nervosa (BN). The aim of this research was to investigate the brain activity patterns associated with viewing food stimuli in anorexia nervosa and bulimia nervosa.

METHODS

Electronic databases including PsycInfo and PubMed were systematically searched from data base inception until 1st of December 2020, identifying 14 suitable functional magnetic resonance imaging studies (fMRI), involving 470 participants. ALE meta-analysis was used to statistically analyse the overlap of activation foci from different fMRI studies in response to visual food stimuli.

RESULTS

Comparing patients with AN with healthy control (HC), we detected hypoactivation in brain areas related to reward processing (i.e., amygdala and lentiform nucleus), and interoceptive processing (i.e., insula). In addition, patients with AN showed hyperactivations in cognitive control areas (i.e., prefrontal and anterior cingulate cortex). In contrast, patients with BN exhibited hyperactivations in brain areas related to reward processing (i.e., lentiform nucleus), and interoceptive processing (i.e., insula). Furthermore, patients with BN showed hypoactivations in brain regions associated with cognitive control (i.e., prefrontal and anterior cingulate cortex).

CONCLUSIONS

Our study shows differing neural endotypes of the two types of eating disorders, that underpin their behavioural phenotypes. While exploratory in nature, these findings might be relevant for guiding new emerging therapies, including invasive and non-invasive neuromodulation techniques in treatment of eating disorders.

LEVEL OF EVIDENCE

Level I, meta-analysis.

Orbitofrontal neural dissociation of healthy and unhealthy food reward sensitivity in normal-weight binge eaters

OBJECTIVE

The orbitofrontal cortex (OFC) has been repeatedly found to play an important role in food reward processing and binge eating (BE) episodes. However, most studies have focused mainly on reward-related neural alterations in clinical binge eating patients, with little consideration of preclinical individuals with BE that are more likely to develop from non-clinical individuals to clinical patients in the future. This study aimed to examine whether preclinical binge eaters exhibited OFC-related resting-state functional connectivity (rsFC) in the context of food reward.

METHOD

Binge eaters (BE group, n = 28) and healthy controls (HCs, n = 28) matched for age and body mass index (BMI) underwent rs-fMRI scans and completed self-reported assessment of BE symptoms. Food reward sensitivity was measured using the modified food incentive delay task. Analysis of covariance was used to assess the between-group differences in the medial and lateral OFC (a priori selected regions of interest) connectivity patterns in the context of food reward, while controlling for age, sex, and BMI.

RESULTS

Lower unhealthy food (UF) reward sensitivity was significantly associated with stronger inverse OFC-putamen connectivity for HCs, while the BE group showed no association between UF reward sensitivity and the OFC-putamen connectivity. Higher healthy food (HF) reward sensitivity in the BE group was significantly correlated with stronger positive OFC-middle frontal gyrus and OFC-inferior parietal gyrus connectivity, while the opposite was found for HCs.

CONCLUSIONS

Binge eaters showed less functional synchrony within reward regions contributing to the UF reward sensitivity, but enhanced neural interactions between reward and inhibitory control regions correlated with the HF reward sensitivity. These novel findings may demonstrate the potential orbitofrontal neural dissociation of unhealthy and healthy food reward sensitivity in normal-weight binge eaters.

Phonological working memory is adversely affected in adults with anorexia nervosa: a systematic literature review

PURPOSE

Cognitive restraint has potentiating and deleterious effects on working memory (WM) in anorexia nervosa (AN). Conflicting evidence may be due to heterogeneity of tasks examining different WM components (e.g., verbal/auditory versus visuospatial), and differences in adolescent versus adult AN. Additionally, differential cognitive profiles of restricting versus binge/purging subtypes, comorbid psychiatric disorders and psychotropic medication use may confound findings.

METHODS

To address these conflicts, 25 studies, published between 2016 and 2021, investigating WM in children, adolescents and adults with AN were systematically reviewed using PRISMA guidelines.

RESULTS

In 71% of WM tasks, no difference in performance between AN patients and age-matched controls was reported, while 29% of WM tasks showed worse performance. Adults with AN displayed deficits in 44% of the verbal/auditory tasks, while performance remained unaffected in 86% of visuospatial tasks.

CONCLUSION

Examining age groups and WM subsystems separately revealed novel findings of differentially affected WM components in AN. Comorbidities and psychotropic medications were common among AN participants and should be regarded as critical confounding factors for WM measures. Future studies examining different components of WM, acknowledging these confounding factors, may reveal specific deficits in AN to aid treatment improvement strategies.

LEVEL OF EVIDENCE

I, systematic review.

Childhood maltreatment is associated with cortical thinning in people with eating disorders

Childhood maltreatment (CM) is a non-specific risk factor for eating disorders (ED) and is associated with a greater severity in their clinical presentation and poorer treatment outcome. These data suggest that maltreated people with ED may be biologically other than clinically different from non-maltreated people. The aim of the present study was to investigate cortical thickness (CT), a possible biomarker of neurodevelopment, in people with ED with or without history of CM and in healthy women. Twenty-four healthy women, 26 with anorexia nervosa and 24 with bulimia nervosa underwent a 3T MRI scan. All participants filled in the childhood trauma questionnaire. All neuroimaging data were processed by FreeSurfer. Twenty-four participants with ED were identified as maltreated and 26 participants with ED as non-maltreated. All healthy women were non-maltreated. Compared to healthy women, maltreated people with ED showed lower CT in the left rostral anterior cingulate gyrus, while compared to people with ED without history of CM showed lower CT values in the left superior frontal and in right caudal middle frontal and superior parietal gyri. No significant differences emerged in CT measures between healthy women and people with ED without history of CM. The present findings show for the first time that in adult people with ED childhood maltreatment is associated with cortical thinning in areas implicated in the modulation of brain processes that are acknowledged to play a role in the psychopathology of ED.

Association between high levels of body-esteem and increased degree of midcingulate cortex global connectivity: A resting-state fMRI study

Multiple neuroimaging studies have examined the neural underpinnings of body image disturbances in patients with eating disorders. However, key brain regions related to body image, such as body-esteem (BE), among healthy individuals are understudied. Given the extremely crucial role of BE in eating behaviors and physical and mental health, the current study conducted data-driven analysis and characterized the neurobiological correlates of BE with the network properties of the resting brain using the voxel-wise degree centrality (DC) measures of resting-state functional magnetic resonance imaging (rs-fMRI) data and seed-based resting-state functional connectivity (RSFC). A total of 694 healthy young adults (females = 474, mean age = 18.38 years, range = 17-22) underwent rs-fMRI, and completed the Body-Esteem Scale for Adolescents and Adults, the Eating Disorder Diagnosis Scale, and the Restraint Scale. After correcting for differences in age, gender, body mass index, and head motion, whole-brain correlation analyses revealed that a high level of BE was associated with increased DC within the right midcingulate cortex (MCC) and subsequent high levels of MCC-based RSFC strengths. Furthermore, MCC connectivity patterns related to BE were inversely associated with disordered eating behaviors. These findings suggest that adaptive cognitive and emotional regulation (i.e., self-evaluation and emotion based on body image) may explain the potential relationship between MCC connectivity patterns and BE to a certain extent. As such, future studies should investigate these interesting possibilities.

Low levels of proinflammatory cytokines in a transdiagnostic sample of young male and female early onset eating disorders without any previous treatment: A case control study

Growing interest exists in the association of the immune system and its role in the development and maintenance of eating disorders (ED). Current evidence suggests that serum cytokine levels seem to be elevated in females with anorexia nervosa (AN). However, less is known in bulimia nervosa (BN) and other specified feeding and eating disorders (OSFED), specially in males. We aimed to perform a case-control study in a sample of forty eight young patients (38 females and 10 males) with early diagnosis of AN, BN or OSFED and without any previous treatment, compared with twenty nine healthy controls (19 females and 10 males) matched by age, sex and socioeconomic status. We evaluated eating-related psychopathology and depressive symptoms and measured serum concentration of proinflammatory cytokines IL-1β, IL-6, and TNF-α and anti-inflammatory cytokine IL-10. Contrary to expectations, levels of IL-1β and IL-6 were significantly lower in ED patients, compared with healthy controls. Comparing the different groups of females, we found elevated levels of IL-10 among ED patients therefore supporting the idea of an immunosuppressive status in the early stages. This could indicate that early onset patients without any previous treatment could remain in a reward-dependent state with a lower immune response.

Ketamine as a Novel Psychopharmacotherapy for Eating Disorders: Evidence and Future Directions

Eating disorders (EDs) are serious, life-threatening psychiatric conditions associated with physical and psychosocial impairment, as well as high morbidity and mortality. Given the chronic refractory nature of EDs and the paucity of evidence-based treatments, there is a pressing need to identify novel approaches for this population. The noncompetitive N-methyl-D-aspartate receptor (NMDAr) antagonist, ketamine, has recently been approved for treatment-resistant depression, exerting rapid and robust antidepressant effects. It is now being investigated for several new indications, including obsessive–compulsive, post-traumatic, and substance use disorder, and shows transdiagnostic potential for EDs, particularly among clinical nonresponders. Hence, the aim of this review is to examine contemporary findings on the treatment of EDs with ketamine, whether used as a primary, adjunctive, or combination psychopharmacotherapy. Avenues for future research are also discussed. Overall, results are encouraging and point to therapeutic value; however, are limited to case series and reports on anorexia nervosa. Further empirical research is thus needed to explore ketamine efficacy across ED subgroups, establish safety profiles and optimize dosing, and develop theory-driven, targeted treatment strategies at the individual patient level.

Cortical reorganization of the glutamate synapse in the activity-based anorexia rat model: impact on cognition

Patients suffering from anorexia nervosa (AN) display altered neural activity, morphological, and functional connectivity in the fronto‐striatal circuit. In addition, hypoglutamatergic transmission and aberrant excitability of the medial prefrontal cortex (mPFC) observed in AN patients might underpin cognitive deficits that fuel the vicious cycle of dieting behavior. To provide a molecular mechanism, we employed the activity‐based anorexia (ABA) rat model, which combines the two hallmarks of AN (i.e., caloric restriction and intense physical exercise), to evaluate structural remodeling together with alterations in the glutamatergic signaling in the mPFC and their impact on temporal memory, as measured by the temporal order object recognition (TOOR) test. Our data indicate that the combination of caloric restriction and intense physical exercise altered the homeostasis of the glutamate synapse and reduced spine density in the mPFC. These events, paralleled by an impairment in recency discrimination in the TOOR test, are associated with the ABA endophenotype. Of note, after a 7‐day recovery period, body weight was recovered and the mPFC structure normalized but ABA rats still exhibited reduced post‐synaptic stability of AMPA and NMDA glutamate receptors associated with cognitive dysfunction. Taken together, these data suggest that the combination of reduced food intake and hyperactivity affects the homeostasis of the excitatory synapse in the mPFC contributing to maintain the aberrant behaviors observed in AN patients. Our findings, by identifying novel potential targets of AN, may contribute to more effectively direct the therapeutic interventions to ameliorate, at least, the cognitive effects of this psychopathology.

Altered gray matter volume and functional connectivity in medial orbitofrontal cortex of bulimia nervosa patients: A combined VBM and FC study

Brain structural and functional abnormalities have been shown to be involved in the neurobiological underpinnings of bulimia nervosa (BN), while the mechanisms underlying this dysregulation are unclear. The main goal of this investigation was to explore the presence of brain structural alterations and relevant functional changes in BN. We hypothesized that BN patients had regional gray matter volume abnormalities and corresponding resting-state functional connectivity (rsFC) changes compared with healthy controls. Thirty-one BN patients and twenty-eight matched healthy controls underwent both high-resolution T1-weighted magnetic resonance imaging (MRI) and resting-state functional MRI. Structural analysis was performed by voxel-based morphometry (VBM), with subsequent rsFC analysis applied by a seed-based, whole-brain voxelwise approach using the abnormal gray matter volume (GMV) region of interest as the seed. Compared with the controls, the BN patients showed increased GMV in the left medial orbitofrontal cortex (mOFC). The BN patients also exhibited significantly increased rsFC between the left mOFC and the right superior occipital gyrus (SOG) and decreased rsFC between the left mOFC and the left precentral gyrus, postcentral gyrus, and supplementary motor area (SMA). Furthermore, the z values of rsFC between the left mOFC and right SOG was positively correlated with the Dutch Eating Behavior Questionnaire-external eating scores. Findings from this investigation further suggest that the mOFC plays a crucial role in the neural pathophysiological underpinnings of BN, which may lead to sensorimotor and visual regions reorganization and be related to representations of body image and the drive behind eating behavior. These findings have important implications for understanding neural mechanisms in BN and developing strategies for prevention.

Adolescent female rats prone to the activity based anorexia (ABA) paradigm have altered hedonic responses and cortical astrocyte density compared to resistant animals

OBJECTIVE

Anhedonia, which in part involves the lack of pleasure in consuming palatable food, is a long-lasting symptom observed in patients both when acutely ill and when long term recovered from Anorexia Nervosa. The neurocircuitry underlying this phenomenon is not well understood. Here we use the preclinical activity-based anorexia (ABA) model in adolescent female rats to assess the impact of excessive exercise, limited food intake and acute weight loss, on adolescent female rat orofacial responding to intraoral sucrose, as measured by the taste reactivity test (TRT). Animals were identified as either prone or resistant to this paradigm based on a weight loss criterion. Measures of food intake, running wheel activity, taste reactivity and medial prefrontal cortex astrocyte expression were compared across groups.

METHODS

Adolescent female rats implanted with an intraoral catheter were given a TRT using 1 M (M) sucrose at baseline, max weight loss (25% weight loss from start of ABA or 7 full days on the paradigm) or 10 days recovered from the ABA paradigm. Animals were sacrificed after the final TRT and astrocyte density was measured via immunohistochemistry.

RESULTS

Animals resistant to the ABA paradigm ran less than prone animals during the ABA period. Additionally, we found that resistant animals displayed more cumulative 'liking' responses to sucrose compared to prone animals at maximum weight loss. Finally, we found prone animals 10-days recovered from ABA had reduced medial prefrontal cortex astrocyte density compared to levels in resistant animals.

DISCUSSION

Rats presented with the physiological challenge of the ABA paradigm either adapt their behavior to stabilize their body weight (i.e. resistant), or rapidly lose weight (i.e. prone). Furthermore, we found that prone animals have reduced orofacial responding to 1 M sucrose at maximum weight loss compared to responses in resistant animals, and this anhedonia-like behavior may be a result of reduced astrocyte density that affects cortical function.

Anorexia nervosa, conduct disorder, and the juvenile justice system: a case of applying traditional treatment modalities in a non-traditional setting

Background

Anorexia Nervosa is highly comorbid with depressive, anxiety, and obsessive-compulsive spectrum disorders. However, it has not previously been reported as comorbid with antisocial personality traits, except when substance use disorder is also identified. We present an unusual case of a patient with resistant anorexia nervosa and comorbid conduct disorder. This case was also unique in that the juvenile justice system was involved during treatment.

Case presentation

A 13-year-old female was admitted to our pediatric hospital for the treatment of anorexia nervosa. She had a history of violent behaviors toward family members, often jeopardizing her care. During hospitalization, she physically attacked a physician on her care team shortly before she transitioned to an eating disorders treatment program. She was diagnosed with conduct disorder, and following discharge, she attacked her father in a premeditated act. This led to her entry into the juvenile justice system. While under the custody of the juvenile justice system, she was readmitted to our hospital for further treatment of anorexia nervosa. Our treatment strategy included psychotropics, positive reinforcement, close interdisciplinary coordination among the various hospital teams, and the juvenile justice system. Following discharge from her second hospitalization back to the juvenile detention system, our patient maintained a healthy weight and appeared to show improvements in the cognitive distortions related to her eating disorder.

Conclusions

To our knowledge, this is the first reported successful treatment of an individual with resistant anorexia nervosa and conduct disorder. It was likely a combination of weight gain, psychotropic medications, and the structured milieu provided by the juvenile justice system that led to the effective treatment of our patient. This case illustrates that a non-traditional healthcare setting can be an asset to treatment through persistence and close collaboration across institutions.

Dissociable hormonal profiles for psychopathology and stress in anorexia and bulimia nervosa

BACKGROUND

Anorexia nervosa (AN) and bulimia nervosa (BN) are complex psychiatric conditions, in which both psychological and metabolic factors have been implicated. Critically, the experience of stress can precipitate loss-of-control eating in both conditions, suggesting an interplay between mental state and metabolic signaling. However, associations between psychological states, symptoms and metabolic processes in AN and BN have not been examined.

METHODS

Eighty-five women (n = 22 AN binge/purge subtype, n = 33 BN, n = 30 controls) underwent remote salivary cortisol sampling and a 2-day, inpatient study session to examine the effect of stress on cortisol, gut hormones [acyl-ghrelin, peptide tyrosine tyrosine (PYY) and glucagon-like peptide-1] and food consumption. Participants were randomized to either an acute stress induction or control task on each day, and plasma hormones were serially measured before a naturalistic, ad libitum meal.

RESULTS

Cortisol-awakening response was augmented in AN but not in BN relative to controls, with body mass index explaining the most variance in post-awakening cortisol (36%). Acute stress increased acyl-ghrelin and PYY in AN compared to controls; however, stress did not alter gut hormone profiles in BN. Instead, a group-by-stress interaction showed nominally reduced cortisol reactivity in BN, but not in AN, compared to controls. Ad libitum consumption was lower in both patient groups and unaffected by stress.

CONCLUSIONS

Findings extend previous reports of metabolic dysfunction in binge-eating disorders, identifying unique associations across disorders and under stress. Moreover, we observed disrupted homeostatic signaling in AN following psychological stress, which may explain, in part, the maintenance of dysregulated eating in this serious illness.

Atypical interoception as a common risk factor for psychopathology: A review

The inadequacy of a categorial approach to mental health diagnosis is now well-recognised, with many authors, diagnostic manuals and funding bodies advocating a dimensional, trans-diagnostic approach to mental health research. Variance in interoception, the ability to perceive one's internal bodily state, is reported across diagnostic boundaries, and is associated with atypical functioning across symptom categories. Drawing on behavioural and neuroscientific evidence, we outline current research on the contribution of interoception to numerous cognitive and affective abilities (in both typical and clinical populations), and describe the interoceptive atypicalities seen in a range of psychiatric conditions. We discuss the role that interoception may play in the development and maintenance of psychopathology, as well as the ways in which interoception may differ across clinical presentations. A number of important areas for further research on the role of interoception in psychopathology are highlighted.

Association of Brain Reward Response With Body Mass Index and Ventral Striatal-Hypothalamic Circuitry Among Young Women With Eating Disorders

IMPORTANCE

Eating disorders are severe psychiatric disorders; however, disease models that cross subtypes and integrate behavior and neurobiologic factors are lacking.

OBJECTIVE

To assess brain response during unexpected receipt or omission of a salient sweet stimulus across a large sample of individuals with eating disorders and healthy controls and test for evidence of whether this brain response is associated with the ventral striatal-hypothalamic circuitry, which has been associated with food intake control, and whether salient stimulus response and eating disorder related behaviors are associated.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional functional brain imaging study, young adults across the eating disorder spectrum were matched with healthy controls at a university brain imaging facility and eating disorder treatment program. During a sucrose taste classic conditioning paradigm, violations of learned associations between conditioned visual and unconditioned taste stimuli evoked the dopamine-related prediction error. Dynamic effective connectivity during expected sweet taste receipt was studied to investigate hierarchical brain activation between food intake relevant brain regions. The study was conducted from June 2014 to November 2019. Data were analyzed from December 2019 to February 2020.

MAIN OUTCOMES AND MEASURES

Prediction error brain reward response across insula and striatum; dynamic effective connectivity between hypothalamus and ventral striatum; and demographic and behavior variables and their correlations with prediction error brain response and connectivity edge coefficients.

RESULTS

Of 317 female participants (197 with eating disorders and 120 healthy controls), the mean (SD) age was 23.8 (5.6) years and mean (SD) body mass index was 20.8 (5.4). Prediction error response was elevated in participants with anorexia nervosa (Wilks λ, 0.843; P = .001) and in participants with eating disorders inversely correlated with body mass index (left nucleus accumbens: r = -0.291; 95% CI, -0.413 to -0.167; P < .001; right dorsal anterior insula: r = -0.228; 95% CI, -0.366 to -0.089; P = .001), eating disorder inventory-3 binge eating tendency (left nucleus accumbens: r = -0.207; 95% CI, -0.333 to -0.073; P = .004; right dorsal anterior insula: r = -0.220; 95% CI, -0.354 to -0.073; P = .002), and trait anxiety (left nucleus accumbens: r = -0.148; 95% CI, -0.288 to -0.003; P = .04; right dorsal anterior insula: r = -0.221; 95% CI, -0.357 to -0.076; P = .002). Ventral striatal to hypothalamus directed connectivity was positively correlated with ventral striatal prediction error in eating disorders (r = 0.189; 95% CI, 0.045-0.324; P = .01) and negatively correlated with feeling out of control after eating (right side: r = -0.328; 95% CI, -0.480 to -0.164; P < .001; left side: r = -0.297; 95% CI, -0.439 to -0.142; P = .001).

CONCLUSIONS AND RELEVANCE

The results of this cross-sectional imaging study support that body mass index modulates prediction error and food intake control circuitry in the brain. Once altered, this circuitry may reinforce eating disorder behaviors when paired with behavioral traits associated with overeating or undereating.

Problem-solving therapy-induced amygdala engagement mediates lifestyle behavior change in obesity with comorbid depression: a randomized proof-of-mechanism trial

BACKGROUND

Depression hinders obesity treatment; elucidating mechanisms may enable treatment enhancements.

OBJECTIVES

The aim was to investigate whether changes in neural targets in the negative affect circuit following psychotherapy mediate subsequent changes in weight and behaviors.

METHODS

Adults (n = 108) with obesity and depression were randomly assigned to usual care or an intervention that delivered problem-solving therapy (PST) for depression over 2 mo. fMRI for brain imaging was performed at baseline and 2 mo. BMI, physical activity, and diet were measured at baseline and 12 mo. Mediation analysis assessed between-group differences in neural target changes using t test and correlations between neural target changes and outcome changes (simple and interaction effect) using ordinary least-squares regression.

RESULTS

Compared with usual care, PST led to reductions in left amygdala activation (-0.75; 95% CI: -1.49, -0.01) and global scores of the negative affect circuit (-0.43; -0.81, -0.06), engaged by threat stimuli. Increases in amygdala activation and global circuit scores at 2 mo correlated with decreases in physical activity outcomes at 12 mo in the usual-care group; these relations were altered by PST. In relation to change in leisure-time physical activity, standardized β-coefficients were -0.67 in usual care and -0.01 in the intervention (between-group difference: 0.66; 0.02, 1.30) for change in left amygdala activation and -2.02 in usual care and -0.11 in the intervention (difference: 1.92; 0.64, 3.20) for change in global circuit scores. In relation to change in total energy expenditure, standardized β-coefficients were -0.65 in usual care and 0.08 in the intervention (difference: 0.73; 0.29, 1.16) for change in left amygdala activation and -1.65 in usual care and 0.08 in the intervention (difference: 1.74; 0.85, 2.63) for change in global circuit scores. Results were null for BMI and diet.

CONCLUSIONS

Short-term changes in the negative affect circuit engaged by threat stimuli following PST for depression mediated longer-term changes in physical activity. This trial was registered at www.clinicaltrials.gov as NCT02246413 (https://clinicaltrials.gov/ct2/show/NCT02246413).

Is the Activity-Based Anorexia Model a Reliable Method of Presenting Peripheral Clinical Features of Anorexia Nervosa?

Anorexia nervosa (AN) causes the highest number of deaths among all psychiatric disorders. Reduction in food intake and hyperactivity/increased anxiety observed in AN are also the core features of the activity-based anorexia animal model (ABA). Our aim was to assess how the acute ABA protocol mimics common AN complications, including gonadal and cardiovascular dysfunctions, depending on gender, age, and initial body weight, to form a comprehensive description of ABA as a reliable research tool. Wheel running, body weight, and food intake of adolescent female and male rats were monitored. Electrocardiography, heart rate variability, systolic blood pressure, and magnetic resonance imaging (MRI) measurements were performed. Immediately after euthanasia, tissue fragments and blood were collected for further analysis. Uterine weight was 2 times lower in ABA female rats, and ovarian tissue exhibited a reduced number of antral follicles and decreased expression of estrogen and progesterone receptors. Cardiovascular measurements revealed autonomic decompensation with prolongation of QRS complex and QT interval. The ABA model is a reliable research tool for presenting the breakdown of adaptation mechanisms observed in severe AN. Cardiac and hormonal features of ABA with underlying altered neuroendocrine pathways create a valid phenotype of a human disease.

A Comprehensive Review of Complications and New Findings Associated with Anorexia Nervosa

Anorexia nervosa is a complex and deadly psychiatric disorder. It is characterized by a significant degree of both co-occurring psychiatric diseases and widespread physiological changes which affect nearly every organ system. It is important for clinicians to be aware of the varied consequences of this disorder. Given the high rate of mortality due to AN, there is a need for early recognition so that patients can be referred for appropriate medical and psychiatric care early in the course of the disorder. In this study, we present a comprehensive review of the recent literature describing medical findings commonly encountered in patients with AN. The varied and overlapping complications of AN affect pregnancy, psychological well-being, as well as bone, endocrine, gastrointestinal, cardiovascular, and pulmonary systems.

From Desire to Dread-A Neurocircuitry Based Model for Food Avoidance in Anorexia Nervosa

Anorexia nervosa is a severe psychiatric illness associated with food avoidance. Animal models from Berridge et al. over the past decade showed that environmental ambience, pleasant or fear inducing, can trigger either appetitive (desire) or avoidance (dread) behaviors in animals via frontal cortex, nucleus accumbens dopamine D1 and D2 receptors, and hypothalamus. Those mechanisms could be relevant for understanding anorexia nervosa. However, models that translate animal research to explain the psychopathology of anorexia nervosa are sparse. This article reviews animal and human research to find evidence for whether this model can explain food avoidance behaviors in anorexia nervosa. Research on anorexia nervosa suggests fear conditioning to food, activation of the corticostriatal brain circuitry, sensitization of ventral striatal dopamine response, and alterations in hypothalamic function. The results support the applicability of the animal neurocircuitry derived model and provide directions to further study the pathophysiology that underlies anorexia nervosa.

Lower leptin level at discharge in acute anorexia nervosa is associated with early weight-loss

OBJECTIVE

Predictive values of acute phase metabolic abnormalities of anorexia nervosa (AN) have seldom been studied. As early postrestoration weight loss is associated with poor outcome, discharge biologic parameters were assessed to detect an association with 2-month follow-up weight loss as a proxy to poor outcome.

METHOD

Fasting plasma levels of leptin, acyl-ghrelin, obestatin, PYY, oxytocin and BDNF were measured in 26 inpatients, at inclusion, at discharge and 2 months later. A body mass index less than 18 2-month postdischarge was considered a poor outcome.

RESULTS

Nineteen patients (73%) had a fair outcome and seven (27%) had a poor one with a mean loss of 0.69 versus 4.54 kg, respectively. Only discharge leptin levels were significantly higher in fair versus poor outcome patients (14.1 vs. 7.0 ng/ml, p = 0.006). The logistic regression model using discharge leptin, acyl-ghrelin, obestatin, oxytocin, PYY and BDNF levels as predictors of outcome disclosed a nearly significant effect of leptin (p < 0.10). Receiver operating characteristic analysis showed 11.9 ng/ml was the best value of threshold. Neither clinical variables differed according to outcome.

CONCLUSION

Leptin level may be a biomarker of early weight relapse after acute inpatient treatment of AN. Its clinical usefulness in monitoring care in AN should further be determined.

Resting-state functional network connectivity underlying eating disorder symptoms in healthy young adults

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This study examined the resting-state functional network connectivity underlying eating disorder symptoms in a large sample of healthy young adults (n = 693).

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Individuals with higher levels of eating disorder symptoms displayed weaker intra-network connectivity of the executive control network and basal ganglia network, as well as weaker inter-network connectivity in the three examined networks (i.e., the executive control network, basal ganglia network, and default mode network).

•

The findings suggest that these neural circuits may play a key role in symptoms of disordered eating in healthy adults. They further reveal that the less efficient information exchange within and between intrinsic networks associated with self-referential thinking, inhibitory control, and reward sensitivity are strongly related to eating disorder symptoms.

Previous neuroimaging research of eating disorders such as anorexia nervosa and bulimia nervosa has mainly focused on clinical patients, indicating the crucial role of intrinsic connectivity networks involved in aberrant behavioral control (i.e., executive control network), reward reactivity (i.e., basal ganglia network), and excessive self-focused and body-focused ruminations (i.e., default mode network) in the onset and maintenance of eating disturbances. However, examinations of large-scale resting-state networks that support the role of cognitive control, reward sensitivity, and self-directed thinking in disordered eating have rarely involved non-clinical samples from the general population. This study, involving a total of 693 healthy young adults (68.69% females; mean age, 18.37 years), investigated these issues by using pre-defined functional regions of interest from the executive control network, basal ganglia network, default mode network, and a seed-based region of interest-to-region of interest approach. After statistically controlling for differences in age, sex, body mass index, and head motion, we observed significant associations of higher levels of eating disorder symptoms, especially bulimia-type eating (i.e., binge eating and a combination of binge eating and compensatory behaviors, such as purging via self-induced vomiting or laxative use, and compulsive exercise), with weaker intra-network and inter-network functional synchrony. These results remained significant after excluding underweight, overweight, and obese participants. These findings suggest that these neural circuits may play a key role in the symptoms of disordered eating in healthy adults. They further reveal that the less efficient information exchange within and between intrinsic networks associated with self-referential thinking, inhibitory control, and reward sensitivity are strongly related to eating disorder symptoms.

From the patients' perspective: what it is like to suffer from eating disorders

The available treatments of Eating Disorders (EDs) mirror an excessive focus on symptoms to be eliminated rather than on the acknowledgment of what is relevant from the patient's perspective. This Editorial offers a critical review of the limitations of the DSM-5-oriented approaches, as well as of their extreme consequences, namely ocularcentrism, nosographism, and paternalistic moralism. To overcome these limitations, it is suggested to get back to Psychopathology as the basic science of psychiatric practice whose aim is to grasp the distinctly personal dimension of the patient's experience and to connect understanding with care. With the help of Psychopathology, clinicians engaged in the treatment of ED patients will better make sense of what it is like to suffer from these disorders and be encouraged to suspend their judgment and take patient's perspective in the light of their troubled existence which is rich in meanings and not merely in abnormal beliefs and trivial anomalous behavior. According to these principles, treatment is a journey shared with the patient, which allows her/him to feel recognized and accepted in terms of her/his individuality.

Orexin-A/Hypocretin-1 Controls the VTA-NAc Mesolimbic Pathway via Endocannabinoid-Mediated Disinhibition of Dopaminergic Neurons in Obese Mice

Disinhibition of orexin-A/hypocretin-1 (OX-A) release occurs to several output areas of the lateral hypothalamus (LH) in the brain of leptin knockout obese ob/ob mice. In this study, we have investigated whether a similar increase of OX-A release occurs to the ventral tegmental area (VTA), an orexinergic LH output area with functional effects on dopaminergic signaling at the mesolimbic circuit. By confocal and correlative light and electron microscopy (CLEM) morphological studies coupled to molecular, biochemical, and pharmacological approaches, we investigated OX-A-mediated dopaminergic signaling at the LH-VTA-nucleus accumbens (NAc) pathway in obese ob/ob mice compared to wild-type (wt) lean littermates. We found an elevation of OX-A trafficking and release to the VTA of ob/ob mice and consequent orexin receptor-1 (OX1R)-mediated over-activation of dopaminergic (DA) neurons via phospholipase C (PLC)/diacylglycerol lipase (DAGL-α)-induced biosynthesis of the endocannabinoid 2-arachidonoylglycerol (2-AG). In fact, by retrograde signaling to cannabinoid receptor type 1 (CB1R) at inhibitory inputs to DA neurons, 2-AG inhibited GABA release thus inducing an increase in DA concentration in the VTA and NAc of ob/ob mice. This effect was prevented by the OX1R antagonist SB-334867 (30 mg/Kg, i.p.), or the CB1R antagonist AM251 (10 mg/Kg, i.p.) and mimicked by OX-A injection (40 μg/Kg, i.p.) in wt lean mice. Enhanced DA signaling to the NAc in ob/ob mice, or in OX-A-injected wt mice, was accompanied by β-arrestin2-mediated desensitization of dopamine D2 receptor (D2R) in a manner prevented by SB-334867 or the D2R antagonist L741 (1.5 mg/Kg, i.p.). These results further support the role of OX-A signaling in the control of neuroadaptive responses, such as compulsive reward-seeking behavior or binge-like consumption of high palatable food, and suggest that aberrant OX-A trafficking to the DA neurons in the VTA of ob/ob mice influences the D2R response at NAc, a main target area of the mesolimbic pathway, via 2-AG/CB1-mediated retrograde signaling.

Is Serum BDNF Altered in Acute, Short- and Long-Term Recovered Restrictive Type Anorexia Nervosa?

Brain-derived neurotrophic factor (BDNF), a neurotrophin involved in the regulation of food intake and body weight, has been implicated in the development and maintenance of Anorexia nervosa (AN). The majority of previous studies reported lower BDNF levels in acutely underweight AN patients (acAN) and increasing levels after weight rehabilitation. Here, we investigated serum BDNF concentrations in the largest known AN sample to date, both before and after weight restoration therapy. Serum BDNF was measured in 259 female volunteers: 77 in-patient acAN participants of the restrictive type (47 reassessed after short-term weight rehabilitation), 62 individuals long-term recovered from AN, and 120 healthy controls. We validated our findings in a post-hoc mega-analysis in which we reanalyzed combined data from the current sample and those from our previous study on BDNF in AN (combined sample: 389 participants). All analyses carefully accounted for known determinants of BDNF (age, sex, storage time of blood samples). We further assessed relationships with relevant clinical variables (body-mass-index, physical activity, symptoms). Contrary to our hypotheses, we found zero significant differences in either cross-sectional or longitudinal comparisons and no significant relationships with clinical variables. Together, our study suggests that BDNF may not be a reliable state- or trait-marker in AN after all.

An update on eating disorders

Eating disorders are heterogeneous disorders characterised by a maladaptive drive to lose weight and, for the most part, by extreme fear of weight gain and overvaluation of thin body image. Calorie restriction, overexercise and purging behaviours put some sufferers at high risk of physical morbidity and mortality. Mental preoccupations interfere with social, professional and general quality of life. Patients’ defensive secrecy and compulsivity can make it hard to diagnose and treat such disorders despite the suffering they involve. Integrated medical and psychiatric intervention can save life and safely improve nutrition. Behavioural support – with family and carer involvement when appropriate – can counter the dysregulation that leads to vicious cycles of restriction–binge–purge, helping patients develop new skills to regulate emotion without weight losing. In the future, exciting developments in neuroimaging, neurosurgery and pharmacology may lead to ways to make the brain more responsive to therapy. Insights into risk factors may also improve preventive strategies in a climate of highly sophisticated international electronic communication.

DNA methylation of ghrelin and leptin receptors in underweight and recovered patients with anorexia nervosa

Epigenetic mechanisms, which modulate gene expression, are becoming increasingly important in the research on anorexia nervosa (AN). Patients with AN have difficulties with the perception of hunger even though hormones like high ghrelin and low leptin signal the need for energy intake. Given the prominent role of the growth hormone secretagogue receptor (GHS-R1a) and the leptin receptor (LEPR) in appetite regulation, a dysregulation of the receptors' expression levels, possibly resulting from altered DNA promoter methylation, may contribute to the pathophysiology of AN. Such alterations could be secondary effects of undernutrition (state markers) or biological processes that may play an antecedent, possibly causal, role in the pathophysiology (trait markers). Therefore, the objective of this study was to examine DNA promoter methylation of the GHS-R1a and LEPR gene promoter regions and investigate whether methylation levels are associated with AN symptoms. We studied medication-free underweight patients with acute AN as well as weight-recovered patients and normal-weight, healthy female control subjects. While DNA methylation of the LEPR gene was similar across groups, GHS-R1a promoter methylation was increased in underweight AN compared to healthy controls - a finding which can be interpreted within the framework of the "ghrelin-resistance" hypothesis in AN. The results of the current study suggest for the first time a potential epigenetic mechanism underlying altered GHS-R1a sensitivity or altered ghrelin signaling in acutely underweight AN. If a ghrelin-centered model of AN can be verified, a next step could be the search for a dietary or psychopharmacological modulation at the ghrelin receptor, potentially via epigenetic mechanisms.

The relationship between eating disorder psychopathology and sexuality: etiological factors and implications for treatment

PURPOSE OF REVIEW

There is a remarkable overlap between eating disorders and sexual problems, both in terms of sexual dysfunctions and risky sexual behaviors. This systematic review of the recent literature aimed at clarifying the nature of this relationship in terms of psychopathological meaning.

RECENT FINDINGS

Body image disturbance, and particularly body dissatisfaction and embodiment disorder, emerged as shared psychopathological dimensions between eating disorder symptoms and sexual dysfunctions. Interpersonal difficulties, a disturbed intimacy and insecure attachment style, but not a history of sexual abuse per se, resulted to play a pivotal role in the interconnection between eating disorder psychopathology and sexual dysfunctions. On the other hand, several studies confirmed the association between eating disorder symptoms and risky sexual behaviors, which has been explained in terms of several common psychopathological dimensions, including impulsivity and addiction.

SUMMARY

Sexuality is deeply interconnected with eating disorder psychopathology, and it should be considered a fundamental aspect in managing these disorders. An accurate assessment of sexual function might allow to characterize etiological information (e.g., sexual abuse) and maintaining factors (embodiment disorder and emotion dysregulation). Accordingly, the recovery of a good sexuality should be considered a crucial signal of recovery.

Short-term metreleptin treatment of patients with anorexia nervosa: rapid on-set of beneficial cognitive, emotional, and behavioral effects

To examine the hypothesis that normalization of low circulating leptin levels in patients with anorexia nervosa ameliorates hyperactivity, three seriously ill females with hyperactivity were treated off-label with metreleptin (recombinant human leptin) for up to 14 days. Drive for activity, repetitive thoughts of food, inner restlessness, and weight phobia decreased in two patients. Surprisingly, depression improved rapidly in all patients. No serious adverse events occurred. Due to obvious limitations of uncontrolled case series, placebo-controlled clinical trials are mandatory to confirm the observed rapid onset of beneficial effects. Our findings suggest an important role of hypoleptinemia in the mental and behavioral phenotype of anorexia nervosa.

Reward and psychopathological correlates of eating disorders: The explanatory role of leptin

It has been hypothesized that leptin level alterations in Eating Disorders (EDs) represent a maintaining factor for pathological reward-related ED behaviors, given leptin role in the dopaminergic reward systems. The aim of the present study was to evaluate the role of leptin in EDs as a mediator for the relationship between Body Mass Index (BMI) and several pathological behaviors, such as dietary restraint, compensatory exercise, vomiting, binge eating and emotional eating. Sixty-two patients with EDs and 41 healthy controls (HC) had their blood drawn and completed psychometric tests for the evaluation of general psychopathology, ED psychopathology and emotional eating. Moderated linear regression models showed that, in the presence of high levels of ED psychopathology, leptin levels were negatively associated with dietary restraint and compensatory exercise, and positively with emotional eating and binge eating. Finally, leptin showed an indirect effect on the association between BMI and all these reward-related behaviors. These results suggest that a variation of BMI maintains these pathological ED behaviors through a variation in leptin levels. Considering the role of leptin in reward circuits, the results seem to confirm an aberrant food-related reward mechanism in ED patients.