Naltrexone in organic bulimia: a preliminary report

Hypothalamic opioid-melanocortin appetitive balance and addictive craving

Whilst the parallels between drug and food craving are receiving increasing attention, the recently elucidated complex physiology of the hypothalamic appetite regulatory centres has been largely overlooked in the efforts to understand drug craving which is one of the most refractory and problematic aspects of drug and behavioural addictions. Important conceptual gains could be made by researchers from both appetite and addiction neuroscience if they were to have an improved understanding of each others' disciplines. It is well known in addiction medicine that the use of many substances is elevated in opiate dependency. There is voluminous evidence of very high rates of drug use in opiate agonist maintained patients, and the real possibility exists that opiate agonist therapy therefore increases drug craving. Conversely, opiate antagonist therapy with naloxone or naltrexone has been shown to reduce most chemical and behavioural addictions, and naltrexone is now being developed together with bupropion as the anti-obesity drug "Contrave". Hypothalamic melanocortins, particularly α-MSH, are known to constitute the main brake to consumptive behaviour of food. There is a well described antagonism between melanocortins and opioids at many loci including the hypothalamus. Administration of exogenous opiates is known to both suppress α-MSH and to stimulate hedonic food consumption. Opiate maintenance programs are associated with weight gain. As monoamines, opioids and cannabinoids are known to be involved in appetite regulation, and as endorphin opioids are known to be perturbed in other addictions, further exploration of the hypothalamic appetite regulatory centre would appear to be an obvious, albeit presently largely overlooked, locus in which to study drug and other craving mechanisms.

Persistent hyperphagia in acquired brain injury; an observational case study of patients receiving inpatient rehabilitation

BACKGROUND

Morbid hunger or persistent hyperphagia is a relatively rare but potentially life threatening complication of acquired brain injury (ABI).

METHOD

This paper presents findings from an observational case study of patients with hyperphagia receiving inpatient neurobehavioural rehabilitation following their acquired brain injury. The case study has utilized dietetic and medical records of identified patients to confirm the persistent and serious nature of this presentation in order to extract important management principles.

RESULTS

The findings confirmed that hyperphagia or morbid hunger posed potentially life-threatening health risks to the patient, primarily around weight control and fluid balance, and risks of aggression towards professional and family carers. Pharmacological or behaviour modification interventions were only partially successful in management of this presentation. The study identified a high need for environmental and cue exposure control in management of this condition.

EXECUTIVE PERSONALITY TRAITS AND EATING BEHAVIOR

Eating disorders, such as anorexia, bulimia, and binge eating disorder, commonly involve a dysregulation of behavior (e.g., a lack or excess of inhibition and impulsive eating patterns) that is suggestive of prefrontal dysfunction. Functional neuro-imaging studies show that prefrontal-subcortical systems play a role in eating behavior and appetite in healthy individuals, and that people with eating disorders have altered activity in these systems. Eating behavior is often disturbed by illnesses and injuries that impinge upon prefrontal-subcortical systems. This study examined relationships between executive functioning and eating behavior in healthy individuals using validated behavioral rating scales (Frontal Systems Behavior Scale and Eating Inventory). Correlations demonstrated that increased dysexecutive traits were associated with disinhibited eating and greater food cravings. There was also a positive association with cognitive restraint of eating, suggesting that increased compensatory behaviors follow disinhibited eating. These psychometric findings reinforce those of other methodologies, supporting a role for prefrontal systems in eating.

Advances in neuropharmacological rehabilitation for brain dysfunction

The use of pharmacological agents as rehabilitative tools following brain injury remains to some degree both a science and an art. Recent work in the area of the neural sciences has shed new light on the workings of basic CNS neurochemical systems and the use of pharmacologic agents in altering central neurophysiologic processes. The major central neurochemical systems are reviewed both anatomically and physiologically. An overview is provided of basic neuropharmacologic agents by class. Lastly, some of the newer neuropharmacological options for treatment of post-acute brain injury deficits are examined.

Time interval of oral feeding recovery as a prognostic factor in severe traumatic brain injury

PRIMARY OBJECTIVES

To assess the outcome of severe traumatic brain injury at least 1 year after trauma, in relation to some early clinical prognostic factors occurring during coma recovery.

RESEARCH DESIGN

Retrospective study conducted at the post-coma unit of a rehabilitation hospital.

METHODS AND PROCEDURES

A total of 43 patients were included. All of the patients sustained severe traumatic brain injury and prolonged coma, i.e. coma lasting at least 15 days. Outcome was assessed by means of Glasgow Coma Scale, Barthel Index and Mini Mental State 1 year after trauma, in relation to some early clinical prognostic factors occurring during coma recovery.

MAIN OUTCOMES AND RESULTS

At the 1 year follow-up, a statistically significant correlation was found with both the Glasgow Outcome Scale and the Barthel Index for the time interval from brain injury to recovery of the following clinical variables: optical fixation, ability to obey commands, spontaneous motor activity and first safe oral feeding. Psychomotor agitation and bulimia were also favourable prognostic factors for the final outcome.

CONCLUSIONS

In the present study, first safe oral feeding during coma recovery represents the clinical feature that better predicts the final outcome of patients with severe traumatic brain injury and prolonged coma.

Neuropsychiatric sequelae of traumatic brain injury

The authors review the psychiatric disturbances associated with traumatic brain injury. They highlight the close link between traumatic brain injury and psychiatry and provide an overview of the epidemiology, risk factors, classification, and mechanisms of traumatic brain injury. They describe various neuropsychiatric sequelae, and the respective treatments are outlined with emphasis on a multidisciplinary approach.

Reducing naltrexone-resistant hyperphagia using laser acupuncture to increase endogenous opiates

A 28-year-old woman with acquired brain damage suffered subsequent profound mental disability and an intense hyperphagic syndrome complete with life-threatening pica. She was the single subject of two consecutive experiments. In the first, Naltrexone, an orally administered opiate blocker, was given to reduce hyperphagia and distress, but was associated with even greater urgency when eating meals and a manifest increase in distress. While distress reduced to premedication levels on withdrawal of treatment, urgency of eating did not reduce so quickly. In the second experiment a laser acupuncture procedure was used at 2.5 Hz and 10 Hz for 10 days each with an intervening 10-day placebo condition to increase the availability of the subject's endogenous opiates, and thus hopefully produce opposite effects to the first experiment and effect a positive treatment. The 10 Hz condition produced a significant but transient reduction in pica measured by attempts at pica on a supervised walk shortly after each treatment. The subject was also easier to manage on walks, and appeared happier. Further studies using physical exercise or acupressure to achieve similar or better results are discussed.

Anorexia due to brain injury

A woman with severe anorexia following a brain injury, who had been fitted with a gastrostomy, was admitted to the Regional Brain Injury Unit for rehabilitation. Two years after the injury, all her dietary intake is oral but she will not yet ingest solids. The causes of this condition and its management are described and the literature is reviewed.