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Giordano U, Mizera J, Żak E, Pilch J, Tomecka P, Dudzik T, Palczewski M, Biziorek W, Piotrowski P. Surgical treatment methods in the course of psychiatric disorders: Deep brain stimulation-Novel insights and indications. Indian J Psychiatry 2023; 65:799-807. [PMID: 37736228 PMCID: PMC10510643 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_266_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/06/2023] [Accepted: 07/12/2023] [Indexed: 09/23/2023] Open
Abstract
Deep brain stimulation (DBS) is a relatively dated treatment procedure that emerged in the late 1980s. Nonetheless, numerous studies are being carried out to examine its influence on the human brain and develop new treatment indications. This systematic review aims to summarize the current state of knowledge referring to DBS, investigate novel insights into its indications, and discuss the technical aspects and rationale behind DBS application. In particular, we sought to subject to scrutiny the application of DBS specifically in anorexia nervosa (AN), various addiction types, depression, and obsessive-compulsive disorders (OCDs). The method is supposed to offer promising results, especially in pharmacologically resistant forms of the upper-mentioned psychiatric disorders. Moreover, further insight has been provided into the historical notions of the method and differences in the surgical approach in specific disease entities. Furthermore, we mark the possible influence of comorbidities on treatment results. Our review consists of articles and studies found on PubMed, Google Scholar, Cochrane, and Scopus, which were then analyzed with scrutiny in the identification process, including the most resourceful ones. After methodological quality and risk of bias assessment, a total of 53 studies were included. To this date, DBS's usefulness in the treatment of AN, OCDs, depression, and addictions has been proven, despite an ongoing debate concerning the technical aspects and parameters when applying DBS. To the best of our knowledge, we have not found any paper that would recapitulate the current state of DBS in the context of psychiatric disorders with an addition of technical insights.
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Affiliation(s)
- Ugo Giordano
- Department of Psychiatry, University Clinical Hospital (USK) in Wroclaw, Wroclaw Medical University, Wroclaw, Poland
| | - Jakub Mizera
- Department of Psychiatry, Students Scientific Association at the Clinic of Psychiatry, Wroclaw Medical University, Wroclaw, Poland
| | - Elżbieta Żak
- Department of Psychiatry, Students Scientific Association at the Clinic of Psychiatry, Wroclaw Medical University, Wroclaw, Poland
| | - Justyna Pilch
- Department of Psychiatry, Students Scientific Association at the Clinic of Psychiatry, Wroclaw Medical University, Wroclaw, Poland
| | - Paulina Tomecka
- Department of Psychiatry, Students Scientific Association at the Clinic of Psychiatry, Wroclaw Medical University, Wroclaw, Poland
| | - Tomasz Dudzik
- Department of Psychiatry, Students Scientific Association at the Clinic of Psychiatry, Wroclaw Medical University, Wroclaw, Poland
| | - Mikołaj Palczewski
- Department of Psychiatry, Students Scientific Association at the Clinic of Psychiatry, Wroclaw Medical University, Wroclaw, Poland
| | - Weronika Biziorek
- Department of Psychiatry, Students Scientific Association at the Clinic of Psychiatry, Wroclaw Medical University, Wroclaw, Poland
| | - Patryk Piotrowski
- Department of Psychiatry, University Clinical Hospital (USK) in Wroclaw, Wroclaw Medical University, Wroclaw, Poland
- Department of Psychiatry, Students Scientific Association at the Clinic of Psychiatry, Wroclaw Medical University, Wroclaw, Poland
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2
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Chae Y, Lee IS. Central Regulation of Eating Behaviors in Humans: Evidence from Functional Neuroimaging Studies. Nutrients 2023; 15:3010. [PMID: 37447336 PMCID: PMC10347214 DOI: 10.3390/nu15133010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
Neuroimaging has great potential to provide insight into the neural response to food stimuli. Remarkable advances have been made in understanding the neural activity underlying food perception, not only in normal eating but also in obesity, eating disorders, and disorders of gut-brain interaction in recent decades. In addition to the abnormal brain function in patients with eating disorders compared to healthy controls, new therapies, such as neurofeedback and neurostimulation techniques, have been developed that target the malfunctioning brain regions in patients with eating disorders based on the results of neuroimaging studies. In this review, we present an overview of early and more recent research on the central processing and regulation of eating behavior in healthy and patient populations. In order to better understand the relationship between the gut and the brain as well as the neural mechanisms underlying abnormal ingestive behaviors, we also provide suggestions for future directions to enhance our current methods used in food-related neuroimaging studies.
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Affiliation(s)
- Younbyoung Chae
- College of Korean Medicine, Kyung Hee University, Seoul 02447, Republic of Korea
| | - In-Seon Lee
- College of Korean Medicine, Kyung Hee University, Seoul 02447, Republic of Korea
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3
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Efficiency of Transcranial Direct Current Stimulation (tDCS) in Anorexia Nervosa Treatment- Case Report. CURRENT PROBLEMS OF PSYCHIATRY 2022. [DOI: 10.2478/cpp-2022-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction: Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation with considerable potential as a treatment for many CNS disorders. Individuals suffering from eating disorders have elevated rates of lifetime depression, anxiety and obsessive-compulsive disorder, also affecting specific brain regions. More studies assess the effect of brain modulation in anorexia nervosa (AN). This study aimed to evaluate the effect, tolerability and safety of tDCS stimulation in the patient with an AN diagnosis.
Material and method: The therapy was implemented in an 18-year-old female hospitalized at the I Department of Psychiatry, Psychotherapy and Early Intervention Medical University of Lublin. The simulation was performed twice daily for 25 minutes for two weeks, 20 sessions. To assess a. anthropometric measures, bioelectrical impedance analysis was conducted; b. biological factors fasting venous blood was drawn; c. psychological aspects: Eating Attitudes Test, Rosenberg self-esteem scale, Beck Depression Inventory, Eating Disorder Examination Questionnaire, Body Esteem Scale, Perceived Stress Scale were used.
Results: The patient responded well to stimulation - apart from a mild headache. After tDCS sessions, improvement in anthropometric measurements, mood, and body self-esteem was observed. No severe changes in blood parameters were observed after the intervention.
Conclusions: Described study case offer preliminary support for achieving meaningful clinical outcomes using transcranial stimulation. However, future clinical studies compared to the placebo group are necessary for proposing a new type of AN therapy.
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Keuken MC, Alkemade A, Stevenson N, Innes RJ, Forstmann BU. Structure-function similarities in deep brain stimulation targets cross-species. Neurosci Biobehav Rev 2021; 131:1127-1135. [PMID: 34715147 DOI: 10.1016/j.neubiorev.2021.10.029] [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: 06/11/2021] [Revised: 10/22/2021] [Accepted: 10/24/2021] [Indexed: 11/24/2022]
Abstract
Deep Brain Stimulation (DBS) is an effective neurosurgical treatment to alleviate motor symptoms of advanced Parkinson's disease. Due to its potential, DBS usage is rapidly expanding to target a large number of brain regions to treat a wide range of diseases and neuropsychiatric disorders. The identification and validation of new target regions heavily rely on the insights gained from rodent and primate models. Here we present a large-scale automatic meta-analysis in which the structure-function associations within and between species are compared for 21 DBS targets in humans. The results indicate that the structure-function association for the majority of the 21 included subcortical areas were conserved cross-species. A subset of structures showed overlapping functional association. This can potentially be attributed to shared brain networks and might explain why multiple brain areas are targeted for the same disease or neuropsychiatric disorder.
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Affiliation(s)
- Max C Keuken
- Integrative Model-based Cognitive Neuroscience Research Unit, University of Amsterdam, Nieuwe Achtergracht 129B, Postbus 15926, 1001 NK, Amsterdam, The Netherlands.
| | - Anneke Alkemade
- Integrative Model-based Cognitive Neuroscience Research Unit, University of Amsterdam, Nieuwe Achtergracht 129B, Postbus 15926, 1001 NK, Amsterdam, The Netherlands
| | - Niek Stevenson
- Integrative Model-based Cognitive Neuroscience Research Unit, University of Amsterdam, Nieuwe Achtergracht 129B, Postbus 15926, 1001 NK, Amsterdam, The Netherlands
| | - Reilly J Innes
- Integrative Model-based Cognitive Neuroscience Research Unit, University of Amsterdam, Nieuwe Achtergracht 129B, Postbus 15926, 1001 NK, Amsterdam, The Netherlands; Newcastle Cognition Lab, University of Newcastle, Callaghan, NSW, Australia
| | - Birte U Forstmann
- Integrative Model-based Cognitive Neuroscience Research Unit, University of Amsterdam, Nieuwe Achtergracht 129B, Postbus 15926, 1001 NK, Amsterdam, The Netherlands
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5
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Fernandes Arroteia I, Husch A, Baniasadi M, Hertel F. Impressive weight gain after deep brain stimulation of nucleus accumbens in treatment-resistant bulimic anorexia nervosa. BMJ Case Rep 2020; 13:e239316. [PMID: 33257397 PMCID: PMC7705521 DOI: 10.1136/bcr-2020-239316] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2020] [Indexed: 11/03/2022] Open
Abstract
Anorexia nervosa (AN) severely impacts individual's mental and physical health as well as quality of life. In 21% of cases no durable response to conservative treatment can be obtained. The serious course of the disease in the most severely affected patients justifies invasive treatment options. One of the treatment methods increasingly used in recent years is deep brain stimulation (DBS). A 42-year-old woman suffering from chronic AN of the bulimic subtype shows a 46.9% weight gain and a subjective increase in quality of life, 12 months after bilateral nucleus accumbens (NAcc) DBS implantation. No improvement in comorbid depression could be achieved. DBS of the NAcc is a treatment option to be considered in severe AN when conventional treatment modalities recommended by evidence-based guidelines have not been able to bring lasting relief to the patient's suffering.
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Affiliation(s)
| | - Andreas Husch
- Luxembourg Centre for Systems Biomedicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Mehri Baniasadi
- Luxembourg Centre for Systems Biomedicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Frank Hertel
- Department of Neurosurgery, Centre Hospitalier de Luxembourg, Luxembourg City, Luxembourg
- Luxembourg Centre for Systems Biomedicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
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Deep brain stimulation (DBS) in resistant mental disorders. CURRENT PROBLEMS OF PSYCHIATRY 2020. [DOI: 10.2478/cpp-2020-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction: Deep Brain Stimulation can directly alter brain activity in a controlled manner and the effect is reversible. The mechanism is that the electrode acts locally on neural activity, which is transferred to monosynchronous and multisynaptic network connections.
Methods: We present studies conducted on a group of patients that show an improvement in mental state after Deep Brain Stimulation.
Material: The diseases we included in our work are: Obsessive-Compulsive Disorder, Eating Disorder, Depression and Bipolar Affective Disorder.
Discussion: The use of deep brain stimulation can inhibit development of acute state of patients and improve both psychiatric features and the time of remission. The results indicate the greatest effectiveness of Deep Brain Stimulation in Obsessive-Compulsive Disorders.
Conclusions: Brain stimulation may be a promising therapeutic target in mental illness. In a properly selected location, it can contribute to a significant clinical improvement however further research in this direction is necessary.
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Wenwen W, Qiongbo WU, Chao Z, Mengya W, Huanhuan Z. [Neural pathway between the nucleus accumbens and the rostral ventrolateral medulla in a rat model of anorexia nervosa]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2020; 40:609-615. [PMID: 32897201 DOI: 10.12122/j.issn.1673-4254.2020.05.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate the potential neural pathway connecting the nucleus accumbens (NAc) and the rostral ventrolateral medulla (RVLM), and whether the pathway participates in the regulation of cardiovascular function in a model rat of anorexia nervosa (AN). METHODS Rat models of AN were established by allowing voluntary activity in a running wheel with restricted feeding, with the rats having free access to normal chow without exercise as the control group. FluoroGold (FG) retrograde tracing method and multi-channel simultaneous recording technique were used to explore the possible pathway between the NAc and the RVLM. RESULTS The rats in AN group exhibited significantly reduced systolic blood pressure (SBP), mean arterial pressure (MAP) and heart rate (HR) with significantly increased discharge frequency of RVLM neurons in comparison with the control rats. After the injection of FG into the RVLM, retrograde labeled neurons were observed in the NAc of the rats in both the normal control and AN groups. In both groups, SBP and HR were significantly decreased in response to 400 μA electrical stimulation of the NAc accompanied by an obvious increase in the discharge frequency of the RVLM neurons; the diastolic blood pressure (DBP) and MAP were significantly lower in AN model rats than in the normal rats in response to the stimulation. CONCLUSIONS We successfully established a rat model of AN via hyperactivity and restricted feeding and confirm the presence of a neural pathway connecting the NAc and the RVLM. This pathway might participate in the regulation of cardiovascular function in AN model rats.
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Affiliation(s)
- Wei Wenwen
- Psychophysiology Laboratory, Wannan Medical College, Wuhu 241002, China.,Cell Electrophysiology Laboratory, Wannan Medical College, Wuhu 241002, China
| | - W U Qiongbo
- Psychophysiology Laboratory, Wannan Medical College, Wuhu 241002, China.,Cell Electrophysiology Laboratory, Wannan Medical College, Wuhu 241002, China
| | - Zheng Chao
- Neurobiology Laboratory, Wannan Medical College, Wuhu 241002, China
| | - Wang Mengya
- Cell Electrophysiology Laboratory, Wannan Medical College, Wuhu 241002, China
| | - Zhang Huanhuan
- Psychophysiology Laboratory, Wannan Medical College, Wuhu 241002, China
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8
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Sobstyl M, Stapińska-Syniec A, Sokół-Szawłowska M, Kupryjaniuk A. Deep brain stimulation for the treatment of severe intractable anorexia nervosa. Br J Neurosurg 2019; 33:601-607. [PMID: 31550921 DOI: 10.1080/02688697.2019.1667484] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Anorexia nervosa (AN) is a challenging multifactorial disorder with the highest mortality rate among all psychiatric disorders. Due to the low rate of long-term treatment success, new treatment options are needed. Here, we review Deep Brain Stimulation (DBS) as a treatment of Severe Intractable AN. The mechanisms of AN have shown significant involvement of the central nervous system especially the same brain regions which are involved with obsessive-compulsive disorder (OCD) and major depressive disorder (MDD). AN and OCD display many similarities in psychiatric practice such as compulsive behaviours and anxiety levels, which are related to networks in the brain, that can be altered using DBS. Our literature search revealed 8 studies totalling 28 individuals with AN and comorbid OCD or MDD. The most common stereotactic targets included the sub-callosal cingulate cortex (Brodmann area 25)/medial forebrain bundle (MFB) for AN and comorbid MDD and nucleus accumbens (NAc)/ventral striatum for AN and comorbid OCD. In most cases bilateral DBS of various structures of the reward system achieved good results in BMI, and core AN symptoms and psychiatric comorbidities showed sustained improvement. DBS is a promising treatment modality for AN and comorbid OCD or MDD. These results highlight promise and hope for patients with AN. However, further studies with larger patient populations are needed to shed light on the long-term outcomes of DBS and its effects in AN treatment.
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Affiliation(s)
- Michał Sobstyl
- Department of Neurosurgery, Institute of Psychiatry and Neurology, Warsaw, Poland
| | | | | | - Anna Kupryjaniuk
- Department of Neurosurgery, Institute of Psychiatry and Neurology, Warsaw, Poland
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9
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How Deep Brain Stimulation of the Nucleus Accumbens Affects the Cingulate Gyrus and Vice Versa. Brain Sci 2019; 9:brainsci9010005. [PMID: 30621216 PMCID: PMC6356752 DOI: 10.3390/brainsci9010005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 12/30/2018] [Indexed: 12/20/2022] Open
Abstract
The nucleus accumbens (NA) and the cingulate gyrus (CG) are two vital limbic brain structures. They have attracted attention as deep brain stimulation (DBS) targets in the treatment of common refractory psychiatric illness. The primary purpose of this article was to review the current knowledge regarding the way that NA DBS affects the CG and vice versa. Methodologically, a thorough literature review was performed. According to the current literature, NA DBS modulates the function of several brain areas including the CG cortex. It specifically causes activation in the ipsilateral CG cortex and voltage-dependent reduction of its blood oxygenation. It also reverses anterior mid-CG cortex dysfunction and decreases metabolism in the subgenual CG. Moreover, NA DBS that induces mirth inhibits the function of the anterior CG cortex and enhances effective connectivity from anterior CG to the ventral striatum. On the other hand, although it is highly probable that CG DBS affects the NA, the exact nature of its effects remains unclear. Despite the increasing interest in psychiatric DBS, the available data on how NA DBS affects the CG and vice versa are restricted. This conclusion probably reflects the high complexity of the limbic circuits and necessitates further research.
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10
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Zanello M, Duriez P, Pallud J, Roux A, Sharshar T, Gorwood P, Devaux B. Letter: Long-Term Follow-up Study of MRI-Guided Bilateral Anterior Capsulotomy in Patients With Refractory Anorexia Nervosa. Neurosurgery 2018; 83:E39-E40. [PMID: 29912370 DOI: 10.1093/neuros/nyy123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Marc Zanello
- Department of Neurosurgery Sainte-Anne Hospital Paris, France.,Paris Descartes University Paris, France
| | - Philibert Duriez
- Paris Descartes University Paris, France.,CMME (Groupe Hospitalier Sainte-Anne) Paris Descartes University Paris, France
| | - Johan Pallud
- Department of Neurosurgery Sainte-Anne Hospital Paris, France.,Paris Descartes University Paris, France
| | - Alexandre Roux
- Department of Neurosurgery Sainte-Anne Hospital Paris, France.,Paris Descartes University Paris, France
| | - Tarek Sharshar
- Paris Descartes University Paris, France.,Anaesthesia and Intensive Care Unit Sainte-Anne Hospital Paris, France
| | - Philip Gorwood
- Paris Descartes University Paris, France.,CMME (Groupe Hospitalier Sainte-Anne) Paris Descartes University Paris, France
| | - Bertrand Devaux
- Department of Neurosurgery Sainte-Anne Hospital Paris, France.,Paris Descartes University Paris, France
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Brimley C, Kershenovich A. Deep brain stimulation lead migration in a child secondary to osteogenesis at the burr hole site. INTERDISCIPLINARY NEUROSURGERY 2018. [DOI: 10.1016/j.inat.2017.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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12
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Park RJ, Scaife JC, Aziz TZ. Study Protocol: Using Deep-Brain Stimulation, Multimodal Neuroimaging and Neuroethics to Understand and Treat Severe Enduring Anorexia Nervosa. Front Psychiatry 2018; 9:24. [PMID: 29681866 PMCID: PMC5898619 DOI: 10.3389/fpsyt.2018.00024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 01/22/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Research suggests that altered eating and the pursuit of thinness in anorexia nervosa (AN) are, in part, a consequence of aberrant reward circuitry. The neural circuits involved in reward processing and compulsivity overlap significantly, and this has been suggested as a transdiagnostic factor underpinning obsessive compulsive disorder, addictions and eating disorders. The nucleus accumbens (NAcc) is central to both reward processing and compulsivity. In previous studies, deep-brain stimulation (DBS) to the NAcc has been shown to result in neural and symptomatic improvement in both obsessive compulsive disorder and addictions. Moreover, in rats, DBS to the NAcc medial shell increases food intake. We hypothesise that this treatment may be of benefit in severe and enduring anorexia nervosa (SE-AN), but first, feasibility and ethical standards need to be established. The aims of this study are as follows: (1) to provide feasibility and preliminary efficacy data on DBS to the NAcc as a treatment for SE-AN; (2) to assess any subsequent neural changes and (3) to develop a neuroethical gold standard to guide applications of this treatment. METHOD This is a longitudinal study of six individuals with SE-AN of >7 years. It includes an integrated neuroethical sub-study. DBS will be applied to the NAcc and we will track the mechanisms underpinning AN using magnetoelectroencephalography, neuropsychological and behavioural measures. Serial measures will be taken on each intensively studied patient, pre- and post-DBS system insertion. This will allow elucidation of the processes involved in symptomatic change over a 15-month period, which includes a double-blind crossover phase of stimulator on/off. DISCUSSION Novel, empirical treatments for SE-AN are urgently required due to high morbidity and mortality costs. If feasible and effective, DBS to the NAcc could be game-changing in the management of this condition. A neuroethical gold standard is crucial to optimally underpin such treatment development. CLINICAL TRIAL REGISTRATION The study is ongoing and registered with www.ClinicalTrials.gov, https://clinicaltrials.gov/ct2/show/NCT01924598, 22 July, 2013. It has full ethical and HRA approval (Project ID 128658).
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Affiliation(s)
- Rebecca J. Park
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford Health NHS Foundation Trust, Oxford, United Kingdom
| | - Jessica C. Scaife
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford Health NHS Foundation Trust, Oxford, United Kingdom
| | - Tipu Z. Aziz
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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Liu W, Li D, Sun F, Zhang X, Wang T, Zhan S, Pan Y, Huang P, Jin H, Li Y, Sun B. Long-Term Follow-up Study of MRI-Guided Bilateral Anterior Capsulotomy in Patients With Refractory Anorexia Nervosa. Neurosurgery 2017; 83:86-92. [DOI: 10.1093/neuros/nyx366] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 08/09/2017] [Indexed: 02/05/2023] Open
Abstract
Abstract
BACKGROUND
Anorexia nervosa (AN) is one of the most challenging psychiatric disorders to treat. The poor clinical outcomes warrant novel treatments for AN, especially in severe and persistent cases.
OBJECTIVE
To explore the feasibility of magnetic resonance imaging-guided bilateral anterior capsulotomy in the treatment of refractory AN.
METHODS
Seventy-four patients diagnosed with refractory AN who underwent capsulotomy completed this 3-yr follow-up study. Outcomes included body mass index (BMI) and results from a series of psychiatric scales (for obsessive, depressive, and anxious symptoms) that were implemented at baseline (presurgery), and 1 mo, 1 yr, and 3 yr after surgery.
RESULTS
Compared to presurgical levels, BMI increased significantly at 1-yr and 3-yr follow-ups. Compared to presurgery scores, psychiatric scale scores were significantly improved at 1-mo postsurgery, and continued to remain low at the 1-yr and 3-yr follow-ups. In addition, Mini-Mental State Examination (MMSE) scores were in the normal range during the long-term follow-up. The most common short-term side effects included urinary incontinence (n = 7), sleep disorders (n = 8), and fatigue (n = 6). Long-term complications included disinhibition (n = 6), memory loss (n = 3), and lethargy (n = 4). No patient in this study experienced death or disability.
CONCLUSION
Capsulotomy enabled patients with refractory AN to normalize their weight, especially those in life-threatening conditions. While it appears to be an acceptable life-saving treatment, it is indicated only when fulfilling strict criteria given its complications and irreversibility.
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Affiliation(s)
- Wei Liu
- Department of Stereotactic and Functional Neurosurgery, Ruijin Hospital, Shanghai, Jiao Tong University School of Medicine, Shanghai, China
| | - Dianyou Li
- Department of Stereotactic and Functional Neurosurgery, Ruijin Hospital, Shanghai, Jiao Tong University School of Medicine, Shanghai, China
| | - Fafa Sun
- Department of Stereotactic and Functional Neurosurgery, Ruijin Hospital, Shanghai, Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoxiao Zhang
- Department of Stereotactic and Functional Neurosurgery, Ruijin Hospital, Shanghai, Jiao Tong University School of Medicine, Shanghai, China
| | - Tao Wang
- Department of Stereotactic and Functional Neurosurgery, Ruijin Hospital, Shanghai, Jiao Tong University School of Medicine, Shanghai, China
| | - Shikun Zhan
- Department of Stereotactic and Functional Neurosurgery, Ruijin Hospital, Shanghai, Jiao Tong University School of Medicine, Shanghai, China
| | - Yixin Pan
- Department of Stereotactic and Functional Neurosurgery, Ruijin Hospital, Shanghai, Jiao Tong University School of Medicine, Shanghai, China
| | - Peng Huang
- Department of Stereotactic and Functional Neurosurgery, Ruijin Hospital, Shanghai, Jiao Tong University School of Medicine, Shanghai, China
| | - Haiyan Jin
- Department of Psychiatry, Ruijin Hospital, Shanghai Jiao Tong University School, of Medicine, Shanghai, China
| | - Yongchao Li
- Department of Psychiatry, Shanghai YangPu District Mental Health Center, Shanghai, China
| | - Bomin Sun
- Department of Stereotactic and Functional Neurosurgery, Ruijin Hospital, Shanghai, Jiao Tong University School of Medicine, Shanghai, China
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Abstract
Eating disorders (EDs), including anorexia nervosa, bulimia nervosa, and binge-eating disorder, constitute a class of common and deadly psychiatric disorders. While numerous studies in humans highlight the important role of neurobiological alterations in the development of ED-related behaviors, the precise neural substrate that mediates this risk is unknown. Historically, pharmacological interventions have played a limited role in the treatment of eating disorders, typically providing symptomatic relief of comorbid psychiatric issues, like depression and anxiety, in support of the standard nutritional and psychological treatments. To date there are no Food and Drug Administration-approved medications or procedures for anorexia nervosa, and only one Food and Drug Administration-approved medication each for bulimia nervosa (fluoxetine) and binge-eating disorder (lisdexamfetamine). While there is little primary interest in drug development for eating disorders, postmarket monitoring of medications and procedures approved for other indications has identified several novel treatment options for patients with eating disorders. In this review, I utilize searches of the PubMed and ClinicalTrials.gov databases to highlight emerging treatments in eating disorders.
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Affiliation(s)
- Michael Lutter
- Eating Recovery Center of Dallas, 4716 Alliance Blvd. #400, Plano, TX, 75093, USA.
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15
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Schippers MC, Gaastra M, Mesman T, Schetters D, van Mourik Y, Denys D, Pattij T, De Vries TJ. Deep brain stimulation of the nucleus accumbens core but not shell reduces motivational components of heroin taking and seeking in rats. Brain Neurosci Adv 2017; 1:2398212817711083. [PMID: 32166132 PMCID: PMC7058223 DOI: 10.1177/2398212817711083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 04/21/2017] [Indexed: 12/04/2022] Open
Abstract
Background: Deep brain stimulation is explored as a new intervention for treatment-resistant substance use dependence. A candidate brain region is the nucleus accumbens, due to its involvement in reward and motivation. This study aimed to explore effects of NAcore and NAshell deep brain stimulation on aspects of heroin taking and seeking in a self-administration model for rats. Methods: NAcore and NAshell deep brain stimulation was applied during 25 or 100 µg/kg/infusion heroin self-administration on an FR4 schedule of reinforcement and during cue- and heroin-induced reinstatement. In a separate group, effects of NAcore deep brain stimulation on heroin self-administration on a progressive ratio schedule and the first extinction session were examined. Results: NAcore and NAshell deep brain stimulation did not alter heroin self-administration on an FR4 schedule. NAcore deep brain stimulation decreased cue – but not drug-induced reinstatement of heroin seeking, whereas NAshell deep brain stimulation did not affect reinstatement responding. In the second experiment, NAcore deep brain stimulation reduced responding during a progressive ratio schedule of heroin reinforcement. Finally, deep brain stimulation facilitated extinction from day 1 throughout the course of extinction learning. Conclusion: Taken together, the differential effects of NAcore and NAshell deep brain stimulation on heroin taking and seeking are in line with the distinct functional roles of these sub-regions therein. Conditioned cues have been shown to be very powerful stimuli for the persistence of addiction and relapse to drug use. Therefore, the present findings that NAcore deep brain stimulation decreases motivation for heroin taking and cue-conditioned behaviour and facilitates extinction learning are very promising, supporting the positive findings from clinical case studies.
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Affiliation(s)
- Maria C Schippers
- Department of Anatomy & Neurosciences, Amsterdam Neuroscience, VU University Medical Center, Amsterdam, The Netherlands
| | - Mathijs Gaastra
- Department of Anatomy & Neurosciences, Amsterdam Neuroscience, VU University Medical Center, Amsterdam, The Netherlands
| | - Tanja Mesman
- Department of Anatomy & Neurosciences, Amsterdam Neuroscience, VU University Medical Center, Amsterdam, The Netherlands
| | - Dustin Schetters
- Department of Anatomy & Neurosciences, Amsterdam Neuroscience, VU University Medical Center, Amsterdam, The Netherlands
| | - Yvar van Mourik
- Department of Anatomy & Neurosciences, Amsterdam Neuroscience, VU University Medical Center, Amsterdam, The Netherlands
| | - Damiaan Denys
- Department of Psychiatry, Amsterdam Neuroscience, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Tommy Pattij
- Department of Anatomy & Neurosciences, Amsterdam Neuroscience, VU University Medical Center, Amsterdam, The Netherlands
| | - Taco J De Vries
- Department of Anatomy & Neurosciences, Amsterdam Neuroscience, VU University Medical Center, Amsterdam, The Netherlands
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Broomfield C, Stedal K, Touyz S, Rhodes P. Labeling and defining severe and enduring anorexia nervosa: A systematic review and critical analysis. Int J Eat Disord 2017; 50:611-623. [PMID: 28444828 DOI: 10.1002/eat.22715] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 03/16/2017] [Accepted: 03/16/2017] [Indexed: 12/24/2022]
Abstract
OBJECTIVE With anorexia nervosa (AN) having various presentations, attention has been directed towards particularly durable forms of the condition in both research and clinical contexts. A major hindrance in terms of advancing the field is the inconsistent labeling and defining of this subgroup. This has two implications; first, the inconsistent recruitment of participants when researching this sample, and second, the misdiagnosing of patients who may or may not have a durable course of the disease. The current research had the purpose of providing an overview of the current labels and criteria used for defining cases of severe and enduring AN, and critically analysing the implications of these findings. METHOD In accordance with PRISMA guidelines, a literature search was conducted using four electronic databases (PsycINFO, MEDLINE, Web of Science and Scopus) in order to identify 32 records that met the standards stipulated by the criteria. Data extraction included explicit labeling, the definition or criteria used to describe the subgroup, along with participant age and study design. RESULTS It was found that the terms chronic and severe and enduring were the most commonly used adjectives when referring to this subgroup. In terms of criteria, illness duration and the number of previously failed treatment attempts were the most common defining features within the literature. DISCUSSION It is the aim of the authors to inspire further research into what is the most appropriate label and defining features for the subgroup in order to facilitate a better approach and outcome for the individuals affected.
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Affiliation(s)
| | - Kristin Stedal
- Regional Department for Eating Disorders, Oslo University Hospital, Ullevål
| | - Stephen Touyz
- Department of Psychology, University of Sydney, Sydney, Australia
| | - Paul Rhodes
- Department of Psychology, University of Sydney, Sydney, Australia
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Graat I, Figee M, Denys D. The application of deep brain stimulation in the treatment of psychiatric disorders. Int Rev Psychiatry 2017; 29:178-190. [PMID: 28523977 DOI: 10.1080/09540261.2017.1282439] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Deep brain stimulation (DBS) is a last-resort treatment for neurological and psychiatric disorders that are refractory to standard treatment. Over the last decades, the progress of DBS in psychiatry has been slower than in neurology, in part owing to the heterogenic symptomatology and complex neuroanatomy of psychiatric disorders. However, for obsessive-compulsive disorder (OCD) DBS is now an accepted treatment. This study first reviews clinical outcomes and mechanisms of DBS for OCD, and then discusses these results in an overview of current and future psychiatric applications, including DBS for mood disorders, Tourette's syndrome, addiction, anorexia nervosa, autism, schizophrenia, and anxiety disorders. In addition, it will focus on novel techniques that may enhance the application of DBS in psychiatry.
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Affiliation(s)
- Ilse Graat
- a Department of Psychiatry , Academic Medical Center, University of Amsterdam , Amsterdam , Netherlands
| | - Martijn Figee
- a Department of Psychiatry , Academic Medical Center, University of Amsterdam , Amsterdam , Netherlands.,b Amsterdam Brain and Cognition , Amsterdam , Netherlands
| | - Damiaan Denys
- a Department of Psychiatry , Academic Medical Center, University of Amsterdam , Amsterdam , Netherlands.,b Amsterdam Brain and Cognition , Amsterdam , Netherlands.,c Netherlands Institute for Neuroscience , An Institute of the Royal Netherlands Academy of Arts and Sciences , Amsterdam , Netherlands
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18
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Schippers MC, Bruinsma B, Gaastra M, Mesman TI, Denys D, De Vries TJ, Pattij T. Deep Brain Stimulation of the Nucleus Accumbens Core Affects Trait Impulsivity in a Baseline-Dependent Manner. Front Behav Neurosci 2017; 11:52. [PMID: 28386221 PMCID: PMC5362621 DOI: 10.3389/fnbeh.2017.00052] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 03/07/2017] [Indexed: 12/29/2022] Open
Abstract
Deep brain stimulation (DBS) of the nucleus accumbens (NA) is explored as a treatment for refractory psychiatric disorders, such as obsessive-compulsive disorder (OCD), depressive disorder (MDD), and substance use disorder (SUD). A common feature of some of these disorders is pathological impulsivity. Here, the effects of NAcore DBS on impulsive choice and impulsive action, two distinct forms of impulsive behavior, were investigated in translational animal tasks, the delayed reward task (DRT) and five-choice serial reaction time task (5-CSRTT), respectively. In both tasks, the effects of NAcore DBS were negatively correlated with baseline impulsive behavior, with more pronounced effects in the 5-CSRTT. To further examine the effects of DBS on trait impulsive action, rats were screened for high (HI) and low (LI) impulsive responding in the 5-CSRTT. NAcore DBS decreased impulsive, premature responding in HI rats under conventional conditions. However, upon challenged conditions to increase impulsive responding, NAcore DBS did not alter impulsivity. These results strongly suggest a baseline-dependent effect of DBS on impulsivity, which is in line with clinical observations.
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Affiliation(s)
- Maria C Schippers
- Amsterdam Neuroscience, Department of Anatomy and Neurosciences, VU University Medical Center Amsterdam, Netherlands
| | - Bastiaan Bruinsma
- Amsterdam Neuroscience, Department of Anatomy and Neurosciences, VU University Medical Center Amsterdam, Netherlands
| | - Mathijs Gaastra
- Amsterdam Neuroscience, Department of Anatomy and Neurosciences, VU University Medical Center Amsterdam, Netherlands
| | - Tanja I Mesman
- Amsterdam Neuroscience, Department of Anatomy and Neurosciences, VU University Medical Center Amsterdam, Netherlands
| | - Damiaan Denys
- Amsterdam Neuroscience, Department of Psychiatry, Academic Medical Center, University of Amsterdam Amsterdam, Netherlands
| | - Taco J De Vries
- Amsterdam Neuroscience, Department of Anatomy and Neurosciences, VU University Medical Center Amsterdam, Netherlands
| | - Tommy Pattij
- Amsterdam Neuroscience, Department of Anatomy and Neurosciences, VU University Medical Center Amsterdam, Netherlands
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19
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Park RJ, Singh I, Pike AC, Tan JOA. Deep Brain Stimulation in Anorexia Nervosa: Hope for the Hopeless or Exploitation of the Vulnerable? The Oxford Neuroethics Gold Standard Framework. Front Psychiatry 2017; 8:44. [PMID: 28373849 PMCID: PMC5357647 DOI: 10.3389/fpsyt.2017.00044] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/03/2017] [Indexed: 01/13/2023] Open
Abstract
Neurosurgical interventions for psychiatric disorders have a long and troubled history (1, 2) but have become much more refined in the last few decades due to the rapid development of neuroimaging and robotic technologies (2). These advances have enabled the design of less invasive techniques, which are more focused, such as deep brain stimulation (DBS) (3). DBS involves electrode insertion into specific neural targets implicated in pathological behavior, which are then repeatedly stimulated at adjustable frequencies. DBS has been used for Parkinson's disease and movement disorders since the 1960s (4-6) and over the last decade has been applied to treatment-refractory psychiatric disorders, with some evidence of benefit in obsessive-compulsive disorder (OCD), major depressive disorder, and addictions (7). Recent consensus guidelines on best practice in psychiatric neurosurgery (8) stress, however, that DBS for psychiatric disorders remains at an experimental and exploratory stage. The ethics of DBS-in particular for psychiatric conditions-is debated (1, 8-10). Much of this discourse surrounds the philosophical implications of competence, authenticity, personality, or identity change following neurosurgical interventions, but there is a paucity of applied guidance on neuroethical best practice in psychiatric DBS, and health-care professionals have expressed that they require more (11). This paper aims to redress this balance by providing a practical, applied neuroethical gold standard framework to guide research ethics committees, researchers, and institutional sponsors. We will describe this as applied to our protocol for a particular research trial of DBS in severe and enduring anorexia nervosa (SE-AN) (https://clinicaltrials.gov/ct2/show/NCT01924598, unique identifier NCT01924598), but believe it may have wider application to DBS in other psychiatric disorders.
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Affiliation(s)
- Rebecca J. Park
- OxBREaD Research Group, Department of Psychiatry, University of Oxford, Oxford, UK
| | - Ilina Singh
- Neuroscience Ethics and Society Research Group, Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Alexandra C. Pike
- OxBREaD Research Group, Department of Psychiatry, University of Oxford, Oxford, UK
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20
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Abstract
Abstract:On seeing promising results in a small number of patients, some researchers are conducting trials to determine whether deep brain stimulation (DBS) is an effective treatment for anorexia nervosa (AN). This article asks whether we should open enrollment in trials of DBS for AN to adolescents. Despite concerns about informed consent, parental consent, and unforeseeable psychological sequelae, the article concludes that the risks to anorexic adolescents associated with participation in trials of DBS are reasonable considering the substantial risks of not enrolling teens with AN in research on DBS. The seriousness of AN, its high incidence in teens, and serious shortfalls in the AN treatment literature point to the need for improved, evidence-based treatments for teens with AN. This unmet need generates an obligation on the part of researchers and physicians to promote and conduct research on AN in adolescents.
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21
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Abstract
Studies published between the beginning of 2013 and May 2015 on the neuropsychological functioning of patients with anorexia nervosa compared with healthy participants framed in the context of the Research Domain Criteria matrix identifies evidence for functional differences in three domains: Negative Valance Systems-negative attentional biases and lack of neural responsivity to hunger; Cognitive Systems-limited congruence between clinical and cognitive performance, poorer non-verbal than verbal performance, altered attentional styles to disorder related stimuli, perceptual processing impairment in discriminating body images, weaknesses in central coherence, set shifting weaknesses at low weight status, decision-making weaknesses, and greater neural resources required for working memory; Systems for Social Processes-patients appear to have a different attentional response to faces, and perception and understanding of self and others. Hence, there is evidence to suggest that patients with anorexia nervosa have a specific neuropsychological performance style across tasks in three domains of functioning. Some current controversies and areas for future development are identified.
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Affiliation(s)
- Marie-Claire Reville
- Feeding and Eating Disorders Service, Department of Child and Adolescent Mental Health, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK.
- College of Life and Environmental Sciences, University of Exeter, Exeter, UK.
| | - Lorna O'Connor
- College of Life and Environmental Sciences, University of Exeter, Exeter, UK
- Department of Psychology, University of Bath, Bath, UK
| | - Ian Frampton
- Feeding and Eating Disorders Service, Department of Child and Adolescent Mental Health, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK
- College of Life and Environmental Sciences, University of Exeter, Exeter, UK
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22
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Neural mechanisms supporting maladaptive food choices in anorexia nervosa. Nat Neurosci 2015; 18:1571-3. [PMID: 26457555 PMCID: PMC4624561 DOI: 10.1038/nn.4136] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 09/16/2015] [Indexed: 11/08/2022]
Abstract
People routinely make poor choices, despite knowledge of negative consequences. We found that individuals with Anorexia Nervosa, who make maladaptive food choices to the point of starvation, engaged the dorsal striatum more than healthy controls when making choices about what to eat, and that activity in fronto-striatal circuits was correlated with their actual food consumption in a meal the next day.
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23
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Touyz S, Hay P. Severe and enduring anorexia nervosa (SE-AN): in search of a new paradigm. J Eat Disord 2015; 3:26. [PMID: 26236477 PMCID: PMC4521346 DOI: 10.1186/s40337-015-0065-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 07/22/2015] [Indexed: 12/22/2022] Open
Affiliation(s)
- Stephen Touyz
- School of Psychology, Faculty of Science, University of Sydney, Sydney, Australia
| | - Phillipa Hay
- Centre for Health Research School of Medicine, University of Western Sydney, Sydney, Australia
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Sgambato-Faure V, Worbe Y, Epinat J, Féger J, Tremblay L. Cortico-basal ganglia circuits involved in different motivation disorders in non-human primates. Brain Struct Funct 2014; 221:345-64. [DOI: 10.1007/s00429-014-0911-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 10/04/2014] [Indexed: 01/29/2023]
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25
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Park RJ, Godier LR, Cowdrey FA. Hungry for reward: How can neuroscience inform the development of treatment for Anorexia Nervosa? Behav Res Ther 2014; 62:47-59. [PMID: 25151600 DOI: 10.1016/j.brat.2014.07.007] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 07/04/2014] [Accepted: 07/16/2014] [Indexed: 12/29/2022]
Abstract
Dysfunctional reward from the pursuit of thinness presents a major challenge to recovery from Anorexia Nervosa (AN). We explore the neuroscientific basis of aberrant reward in AN, with the aim of generating novel hypotheses for translational investigation, and elucidate disease mechanisms to inform the development of targeted interventions. Relevant neuroimaging and behavioural studies are reviewed. These suggest that altered eating in AN may be a consequence of aberrant reward processing combined with exaggerated cognitive control. We consider evidence that such aberrant reward processing is reflected in the compulsive behaviours characterising AN, with substantial overlap in the neural circuits implicated in reward processing and compulsivity. Drawing on contemporary neuroscientific theories of substance dependence, processes underpinning the shift from the initially rewarding pursuit of thinness to extreme and compulsive weight control behaviours are discussed. It is suggested that in AN, weight loss behaviour begins as overtly rewarding, goal-directed and positively reinforced, but over time becomes habitual and increasingly negatively reinforced. Excessive habit formation is suggested as one underlying mechanism perpetuating compulsive behaviour. Ongoing research into the behavioural and neural basis of aberrant reward in AN is required to further elucidate mechanisms. We discuss clinical and transdiagnostic implications, and propose that future treatment innovation may benefit from the development of novel interventions targeting aberrant reward processing in AN.
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Affiliation(s)
- Rebecca J Park
- Department of Psychiatry, University of Oxford, Warneford Hospital, Warneford Lane, Oxford, OX3 7JX, United Kingdom.
| | - Lauren R Godier
- Department of Psychiatry, University of Oxford, Warneford Hospital, Warneford Lane, Oxford, OX3 7JX, United Kingdom
| | - Felicity A Cowdrey
- Department of Psychiatry, University of Oxford, Warneford Hospital, Warneford Lane, Oxford, OX3 7JX, United Kingdom
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