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Marcolini F, Ravaglia A, Tempia Valenta S, Bosco G, Marconi G, De Ronchi D, Atti AR. Severe enduring anorexia nervosa (SE-AN) treatment options and their effectiveness: a review of literature. J Eat Disord 2024; 12:48. [PMID: 38654374 DOI: 10.1186/s40337-024-01006-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 04/16/2024] [Indexed: 04/25/2024] Open
Abstract
INTRODUCTION For nearly 20% of patients diagnosed with Anorexia Nervosa (AN), the eating disorder (ED) is prolonged and becomes long-lasting. It has been reported that patients diagnosed with Severe Enduring Anorexia Nervosa (SE-AN) have worse ED symptoms, higher rates of lifetime hospitalization, and lower psychosocial well-being compared to patients with shorter disease duration. OBJECTIVES This review aims to describe the treatments proposed to date and their effectiveness on SE-AN-related outcomes. METHODS We conducted a PubMed search for studies addressing the issue of treatment approach to SE-AN adults, that were published between 2003 and 2023, peer-reviewed, written in the English language, and available in full-text. Next, we inductively created relevant macro-themes by synthesizing the data from the included articles. RESULTS Of 251 PubMed studies, 25 articles were considered for data extraction, all published between 2003 and 2022. We identified three macro-themes. The first macro-theme, "Psychotherapy", mostly takes into consideration treatment effectiveness of cognitive behavioral therapy (CBT). Various reports determined its greater effectiveness compared to Specialist Supportive Clinical Management (SSCM), and one study proved that outpatient CBT is a valid alternative to hospitalization. The second one involves "Pharmacological Treatments". Research on dronabinol, a synthetic orexigenic cannabinoid, antipsychotics (in particular, olanzapine and haloperidol), and ketamine showed some mixed results regarding the often-complementary areas of weight gain and improvement in ED-related symptoms. Regarding the third macro-theme, "Brain Stimulation Therapies," such as Repetitive Transcranial Magnetic Stimulation (rTMS) and Deep Brain Stimulation (DBS), we found promising results in improving ED-related psychological traits (such as mood and anxiety), affective regulation, and quality of life. However, we have observed divergent results regarding outcome measures such as BMI and weight gain. CONCLUSIONS SE-AN patients are predicted to encounter both medical complications and psychological distress of increasing severity that will inevitably affect their quality of life; to our knowledge, research evidence on treatment options for SE-AN remains limited, and the methodological quality of studies is generally low. These findings denote the need to focus future research efforts on effective treatment strategies specific to long-lasting EDs.
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Affiliation(s)
- Federica Marcolini
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Viale Pepoli 5, 40123, Bologna, Italy.
| | - Alessandro Ravaglia
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Viale Pepoli 5, 40123, Bologna, Italy
| | - Silvia Tempia Valenta
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Viale Pepoli 5, 40123, Bologna, Italy
| | - Giovanna Bosco
- Department of Clinical Nutrition, AUSL Bologna, Bologna, Italy
| | - Giorgia Marconi
- U.O. Cure Primarie, AUSL Area Vasta Romagna, Ambito di Rimini, Rimini, Italy
| | - Diana De Ronchi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Viale Pepoli 5, 40123, Bologna, Italy
| | - Anna Rita Atti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Viale Pepoli 5, 40123, Bologna, Italy
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Miranda-Olivos R, Baenas I, Steward T, Granero R, Pastor A, Sánchez I, Juaneda-Seguí A, Del Pino-Gutiérrez A, Fernández-Formoso JA, Vilarrasa N, Guerrero-Pérez F, Virgili N, López-Urdiales R, Jiménez-Murcia S, de la Torre R, Soriano-Mas C, Fernández-Aranda F. Exploring the influence of circulating endocannabinoids and nucleus accumbens functional connectivity on anorexia nervosa severity. Mol Psychiatry 2023; 28:4793-4800. [PMID: 37759041 PMCID: PMC10914605 DOI: 10.1038/s41380-023-02253-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/31/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023]
Abstract
Anorexia nervosa (AN) is a severe psychiatric disorder characterized by a harmful persistence of self-imposed starvation resulting in significant weight loss. Research suggests that alterations in the nucleus accumbens (NAcc) and circulating endocannabinoids (eCBs), such as anandamide (AEA) and 2-arachidonoylglycerol (2-AG), may contribute to increased severity and maladaptive behaviors in AN, warranting an examination of the interplay between central reward circuitry and eCBs. For this purpose, we assessed NAcc functional connectivity and circulating AEA and 2-AG concentrations in 18 individuals with AN and 18 healthy controls (HC) to test associations between circulating eCBs, NAcc functional connectivity, and AN severity, as defined by body mass index (BMI). Decreased connectivity was observed between the NAcc and the right insula (NAcc-insula; pFWE < 0.001) and the left supplementary motor area (NAcc-SMA; pFWE < 0.001) in the AN group compared to HC. Reduced NAcc-insula functional connectivity mediated the association between AEA concentrations and BMI in the AN group. However, in HC, NAcc-SMA functional connectivity had a mediating role between AEA concentrations and BMI. Although no significant differences in eCBs concentrations were observed between the groups, our findings provide insights into how the interaction between eCBs and NAcc functional connectivity influences AN severity. Altered NAcc-insula and NAcc-SMA connectivity in AN may impair the integration of interoceptive, somatosensory, and motor planning information related to reward stimuli. Furthermore, the distinct associations between eCBs concentrations and NAcc functional connectivity in AN and HC could have clinical implications for weight maintenance, with eCBs being a potential target for AN treatment.
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Affiliation(s)
- Romina Miranda-Olivos
- Clinical Psychology Unit, Bellvitge University Hospital, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
- Ciber Fisiopatología de la Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, 08907, Barcelona, Spain
- Psychoneurobiology of Eating and Addictive Behaviors Research Group, Neurosciences Program, Bellvitge Biomedical Research Institute (IDIBELL), 08908, Barcelona, Spain
- Doctoral Program in Medicine and Translational Research, University of Barcelona, 08036, Barcelona, Spain
| | - Isabel Baenas
- Clinical Psychology Unit, Bellvitge University Hospital, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
- Ciber Fisiopatología de la Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, 08907, Barcelona, Spain
- Psychoneurobiology of Eating and Addictive Behaviors Research Group, Neurosciences Program, Bellvitge Biomedical Research Institute (IDIBELL), 08908, Barcelona, Spain
- Doctoral Program in Medicine and Translational Research, University of Barcelona, 08036, Barcelona, Spain
| | - Trevor Steward
- Melbourne School of Psychological Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, VIC, 3010, Australia
| | - Roser Granero
- Ciber Fisiopatología de la Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, 08907, Barcelona, Spain
- Psychoneurobiology of Eating and Addictive Behaviors Research Group, Neurosciences Program, Bellvitge Biomedical Research Institute (IDIBELL), 08908, Barcelona, Spain
- Department of Psychobiology and Methodology, Autonomous University of Barcelona, 08193, Barcelona, Spain
| | - Antoni Pastor
- Ciber Fisiopatología de la Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, 08907, Barcelona, Spain
- Integrative Pharmacology and Systems Neuroscience research group, Hospital del Mar Research Institute (IMIM), 08003, Barcelona, Spain
| | - Isabel Sánchez
- Clinical Psychology Unit, Bellvitge University Hospital, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
- Ciber Fisiopatología de la Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, 08907, Barcelona, Spain
- Psychoneurobiology of Eating and Addictive Behaviors Research Group, Neurosciences Program, Bellvitge Biomedical Research Institute (IDIBELL), 08908, Barcelona, Spain
| | - Asier Juaneda-Seguí
- Doctoral Program in Medicine and Translational Research, University of Barcelona, 08036, Barcelona, Spain
- Ciber de Salud Mental (CIBERSAM), Instituto Salud Carlos III, 28029, Barcelona, Spain
- Department of Psychiatry, Bellvitge University Hospital-IDIBELL, C/Feixa Llarga s/n, 08907, Barcelona, Spain
| | - Amparo Del Pino-Gutiérrez
- Ciber Fisiopatología de la Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, 08907, Barcelona, Spain
- Psychoneurobiology of Eating and Addictive Behaviors Research Group, Neurosciences Program, Bellvitge Biomedical Research Institute (IDIBELL), 08908, Barcelona, Spain
- Department of Public Health, Mental Health and Perinatal Nursing, School of Nursing, University of Barcelona, 08907, Barcelona, Spain
| | - José A Fernández-Formoso
- Ciber Fisiopatología de la Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, 08907, Barcelona, Spain
| | - Nuria Vilarrasa
- Department of Endocrinology and Nutrition, Bellvitge University Hospital-IDIBELL, C/Feixa Llarga s/n, 08907, Barcelona, Spain
- CIBERDEM-CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, C/Monforte de Lemos 3-5, 28029, Madrid, Spain
| | - Fernando Guerrero-Pérez
- Department of Endocrinology and Nutrition, Bellvitge University Hospital-IDIBELL, C/Feixa Llarga s/n, 08907, Barcelona, Spain
| | - Nuria Virgili
- Department of Endocrinology and Nutrition, Bellvitge University Hospital-IDIBELL, C/Feixa Llarga s/n, 08907, Barcelona, Spain
| | - Rafael López-Urdiales
- Department of Endocrinology and Nutrition, Bellvitge University Hospital-IDIBELL, C/Feixa Llarga s/n, 08907, Barcelona, Spain
| | - Susana Jiménez-Murcia
- Clinical Psychology Unit, Bellvitge University Hospital, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
- Ciber Fisiopatología de la Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, 08907, Barcelona, Spain
- Psychoneurobiology of Eating and Addictive Behaviors Research Group, Neurosciences Program, Bellvitge Biomedical Research Institute (IDIBELL), 08908, Barcelona, Spain
- Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, 08907, Barcelona, Spain
| | - Rafael de la Torre
- Ciber Fisiopatología de la Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, 08907, Barcelona, Spain
- Integrative Pharmacology and Systems Neuroscience research group, Hospital del Mar Research Institute (IMIM), 08003, Barcelona, Spain
- Department of Experimental and Health Sciences, Pompeu Fabra University (CEXS-UPF), 08002, Barcelona, Spain
| | - Carles Soriano-Mas
- Ciber de Salud Mental (CIBERSAM), Instituto Salud Carlos III, 28029, Barcelona, Spain.
- Department of Psychiatry, Bellvitge University Hospital-IDIBELL, C/Feixa Llarga s/n, 08907, Barcelona, Spain.
- Department of Social Psychology and Quantitative Psychology, School of Psychology, University of Barcelona, 08035, Barcelona, Spain.
| | - Fernando Fernández-Aranda
- Clinical Psychology Unit, Bellvitge University Hospital, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.
- Ciber Fisiopatología de la Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, 08907, Barcelona, Spain.
- Psychoneurobiology of Eating and Addictive Behaviors Research Group, Neurosciences Program, Bellvitge Biomedical Research Institute (IDIBELL), 08908, Barcelona, Spain.
- Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, 08907, Barcelona, Spain.
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Oudijn MS, Linders JTW, Lok A, Schuurman PR, van den Munckhof P, van Elburg AA, van Wingen GA, Mocking RJT, Denys D. Neural effects of deep brain stimulation on reward and loss anticipation and food viewing in anorexia nervosa: a pilot study. J Eat Disord 2023; 11:140. [PMID: 37605212 PMCID: PMC10440869 DOI: 10.1186/s40337-023-00863-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 08/08/2023] [Indexed: 08/23/2023] Open
Abstract
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).
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Affiliation(s)
- M S Oudijn
- Department of Psychiatry and Neurosurgery, Amsterdam University Medical Centers (AUMC)-Academic Medical Center (AMC), University of Amsterdam (UvA), PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - J T W Linders
- Department of Psychiatry and Neurosurgery, Amsterdam University Medical Centers (AUMC)-Academic Medical Center (AMC), University of Amsterdam (UvA), PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - A Lok
- Department of Psychiatry and Neurosurgery, Amsterdam University Medical Centers (AUMC)-Academic Medical Center (AMC), University of Amsterdam (UvA), PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - P R Schuurman
- Department of Psychiatry and Neurosurgery, Amsterdam University Medical Centers (AUMC)-Academic Medical Center (AMC), University of Amsterdam (UvA), PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - P van den Munckhof
- Department of Psychiatry and Neurosurgery, Amsterdam University Medical Centers (AUMC)-Academic Medical Center (AMC), University of Amsterdam (UvA), PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - A A van Elburg
- Faculty of Social Sciences, University of Utrecht, Utrecht, The Netherlands
| | - G A van Wingen
- Department of Psychiatry and Neurosurgery, Amsterdam University Medical Centers (AUMC)-Academic Medical Center (AMC), University of Amsterdam (UvA), PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - R J T Mocking
- Department of Psychiatry and Neurosurgery, Amsterdam University Medical Centers (AUMC)-Academic Medical Center (AMC), University of Amsterdam (UvA), PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - D Denys
- Department of Psychiatry and Neurosurgery, Amsterdam University Medical Centers (AUMC)-Academic Medical Center (AMC), University of Amsterdam (UvA), PO Box 22660, 1100 DD, Amsterdam, The Netherlands
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Carrillo-Ruiz JD, Carrillo-Márquez JR, Beltrán JQ, Jiménez-Ponce F, García-Muñoz L, Navarro-Olvera JL, Márquez-Franco R, Velasco F. Innovative perspectives in limbic surgery using deep brain stimulation. Front Neurosci 2023; 17:1167244. [PMID: 37274213 PMCID: PMC10233042 DOI: 10.3389/fnins.2023.1167244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/24/2023] [Indexed: 06/06/2023] Open
Abstract
Limbic surgery is one of the most attractive and retaken fields of functional neurosurgery in the last two decades. Psychiatric surgery emerged from the incipient work of Moniz and Lima lesioning the prefrontal cortex in agitated patients. Since the onset of stereotactic and functional neurosurgery with Spiegel and Wycis, the treatment of mental diseases gave attention to refractory illnesses mainly with the use of thalamotomies. Neurosis and some psychotic symptoms were treated by them. Several indications when lesioning the brain were included: obsessive-compulsive disorder, depression, and aggressiveness among others with a diversity of targets. The indiscriminately use of anatomical sites without enough scientific evidence, and uncertainly defined criteria for selecting patients merged with a deficiency in ethical aspects, brought a lack of procedures for a long time: only select clinics allowed this surgery around the world from 1950 to the 1990s. In 1999, Nuttin et al. began a new chapter in limbic surgery with the use of Deep Brain Stimulation, based on the experience of pain, Parkinson's disease, and epilepsy. The efforts were focused on different targets to treat depression and obsessive-compulsive disorders. Nevertheless, other diseases were added to use neuromodulation. The goal of this article is to show the new opportunities to treat neuropsychiatric diseases.
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Affiliation(s)
- José Damián Carrillo-Ruiz
- Stereotactic, Functional & Radiosurgery Unit of Neurosurgery Service, Mexico General Hospital, Mexico City, Mexico
- Research Direction, Mexico General Hospital, Mexico City, Mexico
- Neuroscience Coordination, Psychology Faculty, Anahuac University, Mexico City, Mexico
| | - José Rodrigo Carrillo-Márquez
- Faculty of Health Sciences, Anahuac University, Mexico City, Mexico
- Alpha Health Sciences Leadership Program, Anahuac University, Mexico City, Mexico
| | - Jesús Quetzalcóatl Beltrán
- Stereotactic, Functional & Radiosurgery Unit of Neurosurgery Service, Mexico General Hospital, Mexico City, Mexico
| | - Fiacro Jiménez-Ponce
- Stereotactic, Functional & Radiosurgery Unit of Neurosurgery Service, Mexico General Hospital, Mexico City, Mexico
| | - Luis García-Muñoz
- Stereotactic, Functional & Radiosurgery Unit of Neurosurgery Service, Mexico General Hospital, Mexico City, Mexico
| | - José Luis Navarro-Olvera
- Stereotactic, Functional & Radiosurgery Unit of Neurosurgery Service, Mexico General Hospital, Mexico City, Mexico
| | - René Márquez-Franco
- Stereotactic, Functional & Radiosurgery Unit of Neurosurgery Service, Mexico General Hospital, Mexico City, Mexico
| | - Francisco Velasco
- Stereotactic, Functional & Radiosurgery Unit of Neurosurgery Service, Mexico General Hospital, Mexico City, Mexico
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Lara-Almunia M, Aguirre-Orue I, Roset-Ferrer C, Bermudez-Andion C, Alvarez AS, Mas-Bonet A, Miguel-Pueyo J, Hernandez-Vicente J. Refractory anorexia nervosa in adulthood and nucleus accumbens deep brain stimulation. Surg Neurol Int 2023; 14:14. [PMID: 36751454 PMCID: PMC9899471 DOI: 10.25259/sni_1112_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 01/01/2023] [Indexed: 01/22/2023] Open
Abstract
Background Anorexia Nervosa is a life-threatening mental illness with numerous consequences. Some cases are chronic and refractory to multiple treatments. Consequently, there is great interest in therapeutic alternatives that may improve severe patients. We present an adult patient with anorexia nervosa that underwent to bilateral nucleus accumbens deep brain stimulation (NAc-DBS). Case description The patient was a healthy 46-year-old woman with higher education and an adequate premorbid socio-labour situation. Her disease had a late onset (25 years). The patient never presented clinical remission or weight stability. In recent years, the patient's body mass index (BMI) was 13.16 (32kg). The case was evaluated with multiple neuropsychological tests as well as the BMI before and after surgery. The clinical follow-up was 50 months. After bilateral NAc-DBS the patient experienced an important clinical benefit and significant improvement in neuropsychological tests and weight (BMI 17.28, 42 kg; 50th month) Programming: 4,5V, 130Hz, 210 µs. Conclusion Despite the patient´s age and the long duration of the disease, our results suggest that bilateral nucleus accumbens stimulation may be a useful and effective therapeutic strategy for cases such as the one presented. Additionally, this case presents a surgical midlife patient with both the latest disease onset and the longest follow-up after treatment in the literature.
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Affiliation(s)
- Monica Lara-Almunia
- Department of Neurosurgery, Jimenez Diaz Foundation University Hospital, Madrid, Spain,Corresponding author: Monica Lara-Almunia, Department of Neurosurgery, Jimenez Diaz Foundation University Hospital, Madrid, Spain.
| | - Iratxe Aguirre-Orue
- Department of Psychiatry and Psychology, Son Espases University Hospital, Palma, Spain
| | - Carolina Roset-Ferrer
- Department of Psychiatry and Psychology, Son Espases University Hospital, Palma, Spain
| | | | - Ana Sofia Alvarez
- Department of Neurosurgery, Jimenez Diaz Foundation University Hospital, Madrid, Spain
| | - Antonio Mas-Bonet
- Department of Radiology, Son Espases University Hospital, Palma, Spain
| | - Jose Miguel-Pueyo
- Department of Psychiatry and Psychology, Son Espases University Hospital, Palma, Spain
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Nagy H, Paul T, Jain E, Loh H, Kazmi SH, Dua R, Rodriguez R, Naqvi SAA, U. MC, Bidika E. A Clinical Overview of Anorexia Nervosa and Overcoming Treatment Resistance. Avicenna J Med 2022; 13:3-14. [PMID: 36969350 PMCID: PMC10038755 DOI: 10.1055/s-0042-1758859] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
AbstractAnorexia nervosa (AN) is a type of eating disorder that has been increasing in incidence and has been encountered more commonly by physicians in their daily practice. Both environmental and genetic risk factors paired along with a more susceptible neurobiology are at play in the emerging resistance to treatment in AN. Preoccupations with intense fear of weight gain, dietary restrictions, excessive exercise, and how the individual is perceived by society mixed with underlying psychopathology all further add to the issue. Many patients who fall into this cycle of obsessive and restrictive patterns refuse to get treatment. As clinicians, it is essential we recognize the early signs of both eating disorders during the initial primary care appointments.To review the literature on the etiology of AN, possible misdiagnosis leading to inappropriate management of this condition, and understand the treatment-resistant AN and its management. Additionally, it will explore possible reasons that contribute to the resistance to treatment, the underlying psychopathology of anorexics, its genetic predisposition, psychiatric comorbidities, identification of the early signs and symptoms, and timely prevention.Early recognition by a physician includes a thorough history and physical examination, pertinent laboratory, and electrolyte studies, and identifying comorbid psychiatric conditions. The treatment of AN is intricate and requires a holistic approach. Treatment includes multiple modalities such as nutritional rehabilitation and psychosocial and pharmacological therapies. An interdisciplinary team of medical professionals for managing chronic AN is recommended.
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Affiliation(s)
- Hassan Nagy
- Division of Research & Academic Affairs, Larkin Health System, South, Miami, Florida, United States
| | - Tanya Paul
- Division of Research & Academic Affairs, Larkin Health System, South, Miami, Florida, United States
| | - Esha Jain
- Division of Research & Academic Affairs, Larkin Health System, South, Miami, Florida, United States
| | - Hanyou Loh
- Division of Research & Academic Affairs, Larkin Health System, South, Miami, Florida, United States
| | - Syeda Hafsa Kazmi
- Division of Research & Academic Affairs, Larkin Health System, South, Miami, Florida, United States
| | - Rishbha Dua
- Division of Research & Academic Affairs, Larkin Health System, South, Miami, Florida, United States
| | - Ricardo Rodriguez
- Division of Research & Academic Affairs, Larkin Health System, South, Miami, Florida, United States
| | - Syed Ali Abbas Naqvi
- Division of Research & Academic Affairs, Larkin Health System, South, Miami, Florida, United States
| | - Metu Chiamaka U.
- Division of Research & Academic Affairs, Larkin Health System, South, Miami, Florida, United States
| | - Erjola Bidika
- Division of Research & Academic Affairs, Larkin Health System, South, Miami, Florida, United States
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Efficacy and safety of deep brain stimulation for treatment-refractory anorexia nervosa: a systematic review and meta-analysis. Transl Psychiatry 2022; 12:333. [PMID: 35970847 PMCID: PMC9378729 DOI: 10.1038/s41398-022-02102-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/14/2022] [Accepted: 07/28/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Several pioneering studies investigated deep brain stimulation (DBS) in treatment-refractory anorexia nervosa (AN) patients, but overall effects remain yet unclear. Aim of this study was to obtain estimates of efficacy of DBS in AN-patients using meta-analysis. METHODS We searched three electronic databases until 1st of November 2021, using terms related to DBS and AN. We included trials that investigated the clinical effects of DBS in AN-patients. We obtained data including psychiatric comorbidities, medication use, DBS target, and study duration. Primary outcome was Body Mass Index (BMI), secondary outcome was quality of life, and the severity of psychiatric symptoms, including eating disorder, obsessive-compulsive, depressive, and anxiety symptoms. We assessed the risk of bias using the ROBINS-I tool. RESULTS Four studies were included for meta-analysis, with a total of 56 patients with treatment-refractory AN. Follow-up ranged from 6-24 months. Random effects meta-analysis showed a significant increase in BMI following DBS, with a large effect size (Hedges's g = 1 ∙ 13; 95% CI = 0 ∙ 80 to 1 ∙ 46; Z-value = 6 ∙ 75; P < 0 ∙ 001), without heterogeneity (I2 = 0 ∙ 00, P = 0 ∙ 901). Random effects meta-analysis also showed a significant increase in quality of life (Hedges's g = 0 ∙ 86; 95% CI = 0 ∙ 44 to 1 ∙ 28; Z-value = 4 ∙ 01, P < 0 ∙ 001). Furthermore, DBS decreased the severity of psychiatric symptoms (Hedges's g = 0 ∙ 89; 95% CI = 0 ∙ 57 to 1 ∙ 21; Z-value = 5 ∙ 47; P < 0 ∙ 001, I2 = 4 ∙ 29, P = 0 ∙ 371). DISCUSSION In this first meta-analysis, DBS showed statistically large beneficial effects on weight restoration, quality of life, and reduction of psychiatric symptoms in patients with treatment-refractory AN. These outcomes call for more extensive naturalistic studies to determine the clinical relevance for functional recovery. This study is preregistered in PROSPERO,CRD42022295712.
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Scaife JC, Eraifej J, Green AL, Petric B, Aziz TZ, Park RJ. Deep Brain Stimulation of the Nucleus Accumbens in Severe Enduring Anorexia Nervosa: A Pilot Study. Front Behav Neurosci 2022; 16:842184. [PMID: 35571282 PMCID: PMC9094709 DOI: 10.3389/fnbeh.2022.842184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/15/2022] [Indexed: 12/17/2022] Open
Abstract
Introduction Anorexia nervosa (AN) is one of the most debilitating psychiatric disorders, becoming severe and enduring in a third of cases; with few effective treatments. Deep brain stimulation is a reversible, adjustable neurosurgical procedure that has been gaining ground in psychiatry as a treatment for depression and obsessive-compulsive disorder, yet few studies have investigated AN. Abnormal eating behavior and the compulsive pursuit of thinness in AN is, in part, a consequence of dysfunction in reward circuitry and the nucleus accumbens (NAcc) is central to reward processing. Methods Phase 1 prospective open-label pilot study of seven individuals with severe enduring AN. Electrodes were implanted bilaterally into the NAcc with stimulation at the anterior limb of the internal capsule using rechargeable implantable pulse generators. The protocol of 15 months included 12 months of deep brain stimulation incorporating two consecutive, randomized blind on-off fortnights 9 months after stimulation onset. The primary objectives were to investigate safety and feasibility, together with changes in eating disorder psychopathology. Results Feasibility and safety was demonstrated with no serious adverse events due to deep brain stimulation. Three patients responded to treatment [defined as > 35% reduction in Eating Disorders Examination (EDE) score at 12 months] and four patients were non-responders. Responders had a statistically significant mean reduction in EDE scores (50.3% reduction; 95% CI 2.6-98.2%), Clinical Impairment Assessment (45.6% reduction; 95% CI 7.4-83.7%). Responders also had a statistically significant mean reduction in Hamilton Depression Scale, Hamilton Anxiety Scale and Snaith-Hamilton pleasure scale. There were no statistically significant changes in Body Mass Index, Yale-Brown-Cornell Eating Disorder Scale, Yale-Brown Obsessive-Compulsive Scale and World Health Organization Quality of Life Psychological subscale. Conclusion This study provides some preliminary indication that deep brain stimulation to the NAcc. Might potentially improve some key features of enduring AN. In this small study, the three responders had comorbid obsessive-compulsive disorder which predated AN diagnosis. Future studies should aim to further elucidate predictors of outcome. Clinical Trial Registration [www.ClinicalTrials.gov], identifier [Project ID 128658].
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Affiliation(s)
- Jessica C. Scaife
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom
- Oxford Health NHS Foundation Trust, Oxford, United Kingdom
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital Oxford, University of Oxford, Oxford, United Kingdom
| | - John Eraifej
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital Oxford, University of Oxford, Oxford, United Kingdom
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Alexander L. Green
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital Oxford, University of Oxford, Oxford, United Kingdom
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Nuffield Department of Clinical Neuroscience, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Beth Petric
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Tipu Z. Aziz
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital Oxford, University of Oxford, Oxford, United Kingdom
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Nuffield Department of Clinical Neuroscience, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Rebecca J. Park
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom
- Oxford Health NHS Foundation Trust, Oxford, United Kingdom
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9
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Messina G, Vetrano IG, Bonomo G, Broggi G. Role of deep brain stimulation in management of psychiatric disorders. PROGRESS IN BRAIN RESEARCH 2022; 270:61-96. [PMID: 35396031 DOI: 10.1016/bs.pbr.2022.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Nowadays, most of patients affected by psychiatric disorders are successfully treated with conservative therapies. Still, a variable percentage of them demonstrate resistance to conventional treatments, and alternative methods can then be considered. During the last 20 years, there is a progressive interest in use of deep brain stimulation (DBS) in mental illnesses. It has become clear nowadays, that this modality may be effectively applied under specific indications in some patients with major depressive disorder, obsessive-compulsive disorder, anorexia nervosa and other eating disorders, Tourette syndrome, schizophrenia, substance use disorder, and even pathologically aggressive behavior. Despite the fact that the efficacy of neuromodulation with DBS, as well as of various lesional interventions, in cases of mental illnesses is still not fully established, there are several premises for wider applications of such "unclassical" psychiatric treatments in the future. Novel technologies of DBS, developments in non-invasive lesioning using stereotactic radiosurgery and transcranial magnetic resonance-guided focused ultrasound, and advances of neurophysiological and neuroimaging modalities may bolster further clinical applications of psychiatric neurosurgery, improve its results, and allow for individually selected treatment strategies tailored to specific needs of the patient.
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Affiliation(s)
- Giuseppe Messina
- Functional Neurosurgery Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Ignazio G Vetrano
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Giulio Bonomo
- Functional Neurosurgery Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Giovanni Broggi
- Functional Neurosurgery Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurosurgery, M Cecilia Hospital-GVM, Ravenna, Italy
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10
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Pérez V, Villalba-Martínez G, Elices M, Manero RM, Salgado P, Ginés JM, Guardiola R, Cedrón C, Polo M, Delgado-Martínez I, Conesa G, Medrano S, Portella MJ. Cognitive and quality-of-life related factors of body mass index (BMI) improvement after deep brain stimulation in the subcallosal cingulate and nucleus accumbens in treatment-refractory chronic anorexia nervosa. EUROPEAN EATING DISORDERS REVIEW 2022; 30:353-363. [PMID: 35322504 DOI: 10.1002/erv.2895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 02/03/2022] [Accepted: 02/22/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Up to 20% of the cases of anorexia nervosa (AN) are chronic and treatment-resistant. Recently, the efficacy of deep brain stimulation (DBS) for severe cases of AN has been explored, with studies showing an improvement in body mass index and other psychiatric outcomes. While the effects of DBS on cognitive domains have been studied in patients with other neurological and psychiatric conditions so far, no evidence has been gathered in AN. METHODS Eight patients with severe, chronic, treatment-resistant AN received DBS either to the nucleus accumbens (NAcc) or subcallosal cingulate (SCC; four subjects on each target). A comprehensive battery of neuropsychological and clinical outcomes was used before and 6-month after surgery. FINDINGS Although Body Mass Index (BMI) did not normalise, statistically significant improvements in BMI, quality of life, and performance on cognitive flexibility were observed after 6 months of DBS. Changes in BMI were related to a decrease in depressive symptoms and an improvement in memory functioning. INTERPRETATION These findings, although preliminary, support the use of DBS in AN, pointing to its safety, even for cognitive functioning; improvements of cognitive flexibility are reported. DBS seems to exert changes on cognition and mood that accompany BMI increments. Further studies are needed better to determine the impact of DBS on cognitive functions.
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Affiliation(s)
- Víctor Pérez
- Institut de Neuropsiquiatria i Addiccions (INAD), Parc de Salut Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.,Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Parce de Salut Mar, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain
| | | | - Matilde Elices
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Parce de Salut Mar, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain
| | - Rosa María Manero
- Department of Neurology, Hospital del Mar, Barcelona, Catalonia, Spain
| | - Purificación Salgado
- Institut de Neuropsiquiatria i Addiccions (INAD), Parc de Salut Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - José María Ginés
- Institut de Neuropsiquiatria i Addiccions (INAD), Parc de Salut Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Rocío Guardiola
- Institut de Neuropsiquiatria i Addiccions (INAD), Parc de Salut Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Carlos Cedrón
- Institut de Neuropsiquiatria i Addiccions (INAD), Parc de Salut Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - María Polo
- Institut de Neuropsiquiatria i Addiccions (INAD), Parc de Salut Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | | | - Gerardo Conesa
- Department of Neurosurgery, Hospital del Mar, Barcelona, Spain
| | - Santiago Medrano
- Department of Radiology, Hospital del Mar, Barcelona, Catalonia, Spain
| | - Maria J Portella
- Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain.,Institut de d'Investigació Biomèdica Sant Pau. Hospital de la Santa Creu i Sant Pau. UAB, Barcelona, Catalonia, Spain
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11
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Braeutigam S, Scaife JC, Aziz T, Park RJ. A Longitudinal Magnetoencephalographic Study of the Effects of Deep Brain Stimulation on Neuronal Dynamics in Severe Anorexia Nervosa. Front Behav Neurosci 2022; 16:841843. [PMID: 35692383 PMCID: PMC9178415 DOI: 10.3389/fnbeh.2022.841843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/22/2022] [Indexed: 11/28/2022] Open
Abstract
Anorexia Nervosa (AN) is a debilitating psychiatric disorder characterized by the relentless pursuit of thinness, leading to severe emaciation. Magnetoencephalography (MEG)was used to record the neuronal response in seven patients with treatment-resistant AN while completing a disorder-relevant food wanting task. The patients underwent a 15-month protocol, where MEG scans were conducted pre-operatively, post-operatively prior to deep brain stimulation (DBS) switch on, twice during a blind on/off month and at protocol end. Electrodes were implanted bilaterally into the nucleus accumbens with stimulation at the anterior limb of the internal capsule using rechargeable implantable pulse generators. Three patients met criteria as responders at 12 months of stimulation, showing reductions of eating disorder psychopathology of over 35%. An increase in alpha power, as well as evoked power at latencies typically associated with visual processing, working memory, and contextual integration was observed in ON compared to OFF sessions across all seven patients. Moreover, an increase in evoked power at P600-like latencies as well as an increase in γ-band phase-locking over anterior-to-posterior regions were observed for high- compared to low-calorie food image only in ON sessions. These findings indicate that DBS modulates neuronal process in regions far outside the stimulation target site and at latencies possibly reflecting task specific processing, thereby providing further evidence that deep brain stimulation can play a role in the treatment of otherwise intractable psychiatric disorders.
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Affiliation(s)
- Sven Braeutigam
- Oxford Centre for Human Brain Activity, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
- Wellcome Centre For Integrative Neuroimaging, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
- Department of Psychiatry, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
- *Correspondence: Sven Braeutigam
| | - Jessica Clare Scaife
- Department of Psychiatry, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
- Oxford Health NHS Foundation Trust, Oxford, United Kingdom
| | - Tipu Aziz
- Nuffield Department of Surgical Sciences, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
- Department of Neurosurgery, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Rebecca J. Park
- Department of Psychiatry, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
- Oxford Health NHS Foundation Trust, Oxford, United Kingdom
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12
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Abstract
PURPOSE OF REVIEW We review recent evidence on the use of neuromodulation for treating eating disorders (EDs), including anorexia nervosa, bulimia nervosa and binge eating disorder. We evaluate studies on (a) modern non-invasive methods of brain stimulation, such as transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), (b) electroconvulsive therapy (ECT) and (c) more invasive techniques, including deep brain stimulation (DBS). RECENT FINDINGS Most reports on the clinical applications of neuromodulation in EDs are limited to case studies, case series and small clinical trials. The majority have focused on severe, enduring and hard-to-treat cases of AN. In this population, data suggest that both rTMS and DBS have therapeutic potential and are safe and acceptable. High-quality clinical trials in different ED populations are needed which investigate different stimulation methods, sites and parameters, the use of neuromodulation as stand-alone and/or adjunctive treatment, as well as the mechanisms of action.
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Affiliation(s)
- L Gallop
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, King's College London, Psychology & Neuroscience, London, UK
| | - M Flynn
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, King's College London, Psychology & Neuroscience, London, UK
| | - I C Campbell
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, King's College London, Psychology & Neuroscience, London, UK
| | - U Schmidt
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, King's College London, Psychology & Neuroscience, London, UK.
- South London and Maudsley NHS Foundation Trust, Maudsley Hospital, London, UK.
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13
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Georgiev D, Akram H, Jahanshahi M. Deep brain stimulation for psychiatric disorders: role of imaging in identifying/confirming DBS targets, predicting, and optimizing outcome and unravelling mechanisms of action. PSYCHORADIOLOGY 2021; 1:118-151. [PMID: 38665808 PMCID: PMC10917192 DOI: 10.1093/psyrad/kkab012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/31/2021] [Accepted: 09/08/2021] [Indexed: 04/28/2024]
Abstract
Following the established application of deep brain stimulation (DBS) in the treatment of movement disorders, new non-neurological indications have emerged, such as for obsessive-compulsive disorders, major depressive disorder, dementia, Gilles de la Tourette Syndrome, anorexia nervosa, and addictions. As DBS is a network modulation surgical treatment, the development of DBS for both neurological and psychiatric disorders has been partly driven by advances in neuroimaging, which has helped explain the brain networks implicated. Advances in magnetic resonance imaging connectivity and electrophysiology have led to the development of the concept of modulating widely distributed, complex brain networks. Moreover, the increasing number of targets for treating psychiatric disorders have indicated that there may be a convergence of the effect of stimulating different targets for the same disorder, and the effect of stimulating the same target for different disorders. The aim of this paper is to review the imaging studies of DBS for psychiatric disorders. Imaging, and particularly connectivity analysis, offers exceptional opportunities to better understand and even predict the clinical outcomes of DBS, especially where there is a lack of objective biomarkers that are essential to properly guide DBS pre- and post-operatively. In future, imaging might also prove useful to individualize DBS treatment. Finally, one of the most important aspects of imaging in DBS is that it allows us to better understand the brain through observing the changes of the functional connectome under neuromodulation, which may in turn help explain the mechanisms of action of DBS that remain elusive.
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Affiliation(s)
- Dejan Georgiev
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, Queen Square, London, WC1N 3BG, UK
- Department of Neurology, University Medical Centre Ljubljana, Zaloška cesta 2, 1000 Ljubljana, Slovenia
- Artificial Intelligence Laboratory, Faculty of Computer and Information Science, University of Ljubljana, Večna pot 113, 1000 Ljubljana, Slovenia
| | - Harith Akram
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, Queen Square, London, WC1N 3BG, UK
| | - Marjan Jahanshahi
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, Queen Square, London, WC1N 3BG, UK
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Laboratory for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, 611731, China
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14
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Dandekar MP, Diaz AP, Rahman Z, Silva RH, Nahas Z, Aaronson S, Selvaraj S, Fenoy AJ, Sanches M, Soares JC, Riva-Posse P, Quevedo J. A narrative review on invasive brain stimulation for treatment-resistant depression. ACTA ACUST UNITED AC 2021; 44:317-330. [PMID: 34468549 PMCID: PMC9169472 DOI: 10.1590/1516-4446-2021-1874] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 04/22/2021] [Indexed: 12/20/2022]
Abstract
While most patients with depression respond to pharmacotherapy and psychotherapy, about one-third will present treatment resistance to these interventions. For patients with treatment-resistant depression (TRD), invasive neurostimulation therapies such as vagus nerve stimulation, deep brain stimulation, and epidural cortical stimulation may be considered. We performed a narrative review of the published literature to identify papers discussing clinical studies with invasive neurostimulation therapies for TRD. After a database search and title and abstract screening, relevant English-language articles were analyzed. Vagus nerve stimulation, approved by the U.S. Food and Drug Administration as a TRD treatment, may take several months to show therapeutic benefits, and the average response rate varies from 15.2-83%. Deep brain stimulation studies have shown encouraging results, including rapid response rates (> 30%), despite conflicting findings from randomized controlled trials. Several brain regions, such as the subcallosal-cingulate gyrus, nucleus accumbens, ventral capsule/ventral striatum, anterior limb of the internal capsule, medial-forebrain bundle, lateral habenula, inferior-thalamic peduncle, and the bed-nucleus of the stria terminalis have been identified as key targets for TRD management. Epidural cortical stimulation, an invasive intervention with few reported cases, showed positive results (40-60% response), although more extensive trials are needed to confirm its potential in patients with TRD.
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Affiliation(s)
- Manoj P Dandekar
- Department of Pharmacology & Toxicology, National Institute of Pharmaceutical Education and Research, Hyderabad, Telangana, India
| | - Alexandre P Diaz
- Center of Excellence on Mood Disorders, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Ziaur Rahman
- Department of Pharmacology & Toxicology, National Institute of Pharmaceutical Education and Research, Hyderabad, Telangana, India
| | - Ritele H Silva
- Laboratório de Psiquiatria Translacional, Programa de Pós-Graduação em Ciências da Saúde, Universidade do Extremo Sul Catarinense (UNESC), Criciúma, SC, Brazil
| | - Ziad Nahas
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA
| | - Scott Aaronson
- Clinical Research Programs, Sheppard Pratt Health System, Baltimore, MD, USA
| | - Sudhakar Selvaraj
- Center of Excellence on Mood Disorders, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Albert J Fenoy
- Center of Excellence on Mood Disorders, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.,Deep Brain Stimulation Program, Department of Neurosurgery, McGovern Medical School, UTHealth, Houston, TX, USA
| | - Marsal Sanches
- Center of Excellence on Mood Disorders, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Jair C Soares
- Center of Excellence on Mood Disorders, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.,Neuroscience Graduate Program, The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX, USA
| | - Patricio Riva-Posse
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA
| | - Joao Quevedo
- Center of Excellence on Mood Disorders, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.,Laboratório de Psiquiatria Translacional, Programa de Pós-Graduação em Ciências da Saúde, Universidade do Extremo Sul Catarinense (UNESC), Criciúma, SC, Brazil.,Neuroscience Graduate Program, The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX, USA.,Translational Psychiatry Program, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, UTHealth, Houston, TX, USA
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15
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Lin Z, Dai L, Zhang C, Li D, Sun B. Rescue Anterior Capsulotomy after Failure of Nucleus Accumbens Deep Brain Stimulation in Anorexia Nervosa: A Case Report. Stereotact Funct Neurosurg 2021; 99:491-495. [PMID: 34218229 DOI: 10.1159/000517105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 04/30/2021] [Indexed: 11/19/2022]
Abstract
Anorexia nervosa (AN) is a highly disabling mental disorder with high rates of morbidity and mortality. Few psychological treatments and pharmacotherapy are proven to be effective for adult AN. Two invasive stereotactic neurosurgical interventions, deep brain stimulation (DBS) and anterior capsulotomy, are now commonly used as investigational approaches for the treatment of AN. Here, we report the long-term safety and efficacy of rescue bilateral anterior capsulotomy after the failure of bilateral nucleus accumbens (NAcc)-DBS in an 18-year-old female patient with life-threatening and treatment-resistant restricting subtype AN. Improvements in the neuropsychiatric assessment were not documented 6 months after the NAcc-DBS. Rescue bilateral anterior capsulotomy was proposed and performed, resulting in a long-lasting restoration of body weight and a significant and sustained remission in AN core symptoms. The DBS pulse generator was exhausted 2 years after capsulotomy and removed 3 years postoperatively. No relapse was reported at the last follow-up (7 years after the first intervention). From this case, we suggest that capsulotomy could be a rescue treatment for patients with treatment-resistant AN after NAcc-DBS failure. Further well-controlled studies are warranted to validate our findings.
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Affiliation(s)
- Zhengyu Lin
- Department of Neurosurgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China, .,Center for Functional Neurosurgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China,
| | - Lulin Dai
- Department of Neurosurgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Center for Functional Neurosurgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chencheng Zhang
- Department of Neurosurgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Center for Functional Neurosurgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dianyou Li
- Department of Neurosurgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Center for Functional Neurosurgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bomin Sun
- Department of Neurosurgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Center for Functional Neurosurgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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16
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Diaz AP, Fernandes BS, Quevedo J, Sanches M, Soares JC. Treatment-resistant bipolar depression: concepts and challenges for novel interventions. ACTA ACUST UNITED AC 2021; 44:178-186. [PMID: 34037084 PMCID: PMC9041963 DOI: 10.1590/1516-4446-2020-1627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/16/2021] [Indexed: 02/06/2023]
Abstract
Treatment-resistant bipolar depression (TRBD) has been reported in about one-quarter of patients with bipolar disorders, and few interventions have shown clear and established effectiveness. We conducted a narrative review of the published medical literature to identify papers discussing treatment-resistant depression concepts and novel interventions for bipolar depression that focus on TRBD. We searched for potentially relevant English-language articles published in the last decade. Selected articles (based on the title and abstract) were retrieved for a more detailed evaluation. A number of promising new interventions, both pharmacological and non-pharmacological, are being investigated for TRBD treatment, including ketamine, lurasidone, D-cycloserine, pioglitazone, N-acetylcysteine, angiotensin-converting enzyme inhibitors, angiotensin II type 1 receptor blockers, cyclooxygenase 2 inhibitors, magnetic seizure therapy, intermittent theta-burst stimulation, deep transcranial magnetic stimulation, vagus nerve stimulation therapy, and deep brain stimulation. Although there is no consensus about the concept of TRBD, better clarification of the neurobiology associated with treatment non-response could help identify novel strategies. More research is warranted, mainly focusing on personalizing current treatments to optimize response and remission rates.
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Affiliation(s)
- Alexandre P Diaz
- Center of Excellence on Mood Disorders, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.,Translational Psychiatry Program, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Brisa S Fernandes
- Center of Excellence on Mood Disorders, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.,Translational Psychiatry Program, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Joao Quevedo
- Center of Excellence on Mood Disorders, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.,Translational Psychiatry Program, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.,Neuroscience Graduate Program, The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX, USA.,Laboratório de Psiquiatria Translacional, Programa de Pós-Graduação em Ciências da Saúde (PPGCS), Universidade do Extremo Sul Catarinense (UNESC), Criciúma, SC, Brazil
| | - Marsal Sanches
- Center of Excellence on Mood Disorders, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Jair C Soares
- Center of Excellence on Mood Disorders, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.,Neuroscience Graduate Program, The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX, USA
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17
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Treasure J, Oyeleye O, Bonin EM, Zipfel S, Fernandez-Aranda F. Optimising care pathways for adult anorexia nervosa. What is the evidence to guide the provision of high-quality, cost-effective services? EUROPEAN EATING DISORDERS REVIEW 2021; 29:306-315. [PMID: 33629403 DOI: 10.1002/erv.2821] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 01/16/2021] [Indexed: 12/18/2022]
Abstract
The aim of this paper is to consider how changes in service planning and delivery might improve the care pathways for adult anorexia nervosa. Although anorexia nervosa has a long history in Europe, its framing as a mental disorder is quite recent. The changing forms and increasing epidemiology of eating disorders has led to the expansion of specialised services. Although some services provide care over the entire clinical course, more often services are divided into those that care for children and adolescents or adults. The transition needs to be carefully managed as currently these services may have a different ethos and expectations. Services for adults have a broad range of diversity (diagnostic subtype, medical severity, comorbidity, stage of illness and psychosocial functioning) all of which impacts on prognosis. A tailored, approach to treatment planning could optimise the pathway. Facilitating early help seeking and rapid diagnosis in primary care and reducing specialised services waiting lists for assessment and treatment could be a form of secondary prevention. The use of precision models and /or continuous outcome monitoring might reduce the third of patients who require more intensive care by applying augmentation strategies. Finally, gains from intensive care might be sustained by relapse prevention interventions and community support to bridge the transition home. Together these measures might reduce the proportion of patients (currently a third) with ill health for over 20 years. For this group rehabilitation strategies may improve functioning until new treatment emerge.
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Affiliation(s)
- Janet Treasure
- Department of Psychological Medicine, Section of Eating Disorders, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK.,South London and Maudsley NHS Foundation Trust, Adult Inpatient Eating Disorders Service, Tyson West 2, Bethlem Royal Hospital, Beckenham, UK
| | - Oyenike Oyeleye
- South London and Maudsley NHS Foundation Trust, Adult Inpatient Eating Disorders Service, Tyson West 2, Bethlem Royal Hospital, Beckenham, UK
| | - Eva-Maria Bonin
- Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Stephan Zipfel
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Hospital, University of Tuebingen, Tübingen, Germany.,Centre of Excellence for Eating Disorders (KOMET), University of Tuebingen, Tübingen, Germany
| | - Fernando Fernandez-Aranda
- Department of Psychiatry, University Hospital of Bellvitge-IDIBELL and CIBERobn, Barcelona, Spain.,Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
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Alternatives to Pharmacological and Psychotherapeutic Treatments in Psychiatric Disorders. PSYCHIATRY INTERNATIONAL 2021. [DOI: 10.3390/psychiatryint2010001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Nowadays, most of the patients affected by psychiatric disorders are successfully treated with psychotherapy and pharmacotherapy. Nevertheless, according to the disease, a variable percentage of patients results resistant to such modalities, and alternative methods can then be considered. The purpose of this review is to summarize the techniques and results of invasive modalities for several treatment-resistant psychiatric diseases. A literature search was performed to provide an up-to-date review of advantages, disadvantages, efficacy, and complications of Deep-Brain Stimulation, Magnetic Resonance-guided Focused-Ultrasound, radiofrequency, and radiotherapy lesioning for depression, obsessive-compulsive disorder, schizophrenia, addiction, anorexia nervosa, and Tourette’s syndrome. The literature search did not strictly follow the criteria for a systematic review: due to the large differences in methodologies and patients’ cohort, we tried to identify the highest quality of available evidence for each technique. We present the data as a comprehensive, narrative review about the role, indication, safety, and results of the contemporary instrumental techniques that opened new therapeutic fields for selected patients unresponsive to psychotherapy and pharmacotherapy.
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Baumann S, Mareš T, Albrecht J, Anders M, Vochosková K, Hill M, Bulant J, Yamamotová A, Štastný O, Novák T, Holanová P, Lambertová A, Papežová H. Effects of Transcranial Direct Current Stimulation Treatment for Anorexia Nervosa. Front Psychiatry 2021; 12:717255. [PMID: 34690831 PMCID: PMC8526853 DOI: 10.3389/fpsyt.2021.717255] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 08/27/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Anorexia nervosa (AN) is a life-threatening illness with poor treatment outcomes. Although transcranial direct current stimulation (tDCS) is a promising non-invasive brain stimulation method, its effect in patients with AN remains unclear. Objective: This study investigated changes in maladaptive eating behavior, body mass index (BMI), and depression after 10 sessions of anodal tDCS over the left dorsolateral prefrontal cortex (DLPFC). Methods: In this double-blind, randomized controlled trial, 43 inpatients with AN were divided to receive either active (n = 22) or sham (n = 21) tDCS over the left DLPFC (anode F3/cathode Fp2, 2 mA for 30 min). All patients filled the Eating Disorder Examination Questionnaire (EDE-Q) and Zung Self-Rating Depression Scale (ZUNG), and their BMI was measured. These values were obtained repeatedly in four stages: (1) before tDCS treatment, (2) after tDCS treatment, (3) in the follow-up after 2 weeks, and (4) in the follow-up after 4 weeks. Results: Primary outcomes (EDE-Q) based on the ANOVA results do not show any between-group differences either after the active part of the study or in the follow-up. Secondary analysis reveals a reduction in some items of EDE-Q. Compared with sham tDCS, active tDCS significantly improved self-evaluation based on body shape (p < 0.05) and significantly decreased the need of excessive control over calorie intake (p < 0.05) in the 4-week follow-up. However, the results do not survive multiple comparison correction. In both sham and active groups, the BMI values improved, albeit not significantly. Conclusion: We did not observe a significant effect of tDCS over the left DLPFC on complex psychopathology and weight recovery in patients with AN. tDCS reduced the need to follow specific dietary rules and improved body image evaluation in patients with AN. Tests with a larger sample and different positions of electrodes are needed. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03273205.
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Affiliation(s)
- Silvie Baumann
- Department of Psychotherapy, National Institute of Mental Health, Klecany, Czechia.,First Faculty of Medicine, Charles University, Prague, Czechia
| | - Tadeáš Mareš
- First Faculty of Medicine, Charles University, Prague, Czechia.,Department of Psychiatry, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czechia
| | - Jakub Albrecht
- First Faculty of Medicine, Charles University, Prague, Czechia.,Department of Psychiatry, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czechia
| | - Martin Anders
- First Faculty of Medicine, Charles University, Prague, Czechia.,Department of Psychiatry, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czechia
| | - Kristýna Vochosková
- Department of Psychotherapy, National Institute of Mental Health, Klecany, Czechia.,Third Faculty of Medicine, Charles University, Prague, Czechia
| | - Martin Hill
- Department of Steroid Hormones and Proteohormones, Institute of Endocrinology, Prague, Czechia
| | - Josef Bulant
- Department of Psychiatry, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czechia.,Department of Steroid Hormones and Proteohormones, Institute of Endocrinology, Prague, Czechia.,Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czechia
| | - Anna Yamamotová
- Department of Physiology, Third Faculty of Medicine, Charles University, Prague, Czechia
| | - Ota Štastný
- Third Faculty of Medicine, Charles University, Prague, Czechia
| | - Tomáš Novák
- Department of Psychotherapy, National Institute of Mental Health, Klecany, Czechia.,Third Faculty of Medicine, Charles University, Prague, Czechia
| | - Petra Holanová
- First Faculty of Medicine, Charles University, Prague, Czechia.,Department of Psychiatry, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czechia
| | - Alena Lambertová
- First Faculty of Medicine, Charles University, Prague, Czechia.,Department of Psychiatry, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czechia
| | - Hana Papežová
- First Faculty of Medicine, Charles University, Prague, Czechia.,Department of Psychiatry, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czechia
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Agüera Z, Jiménez-Murcia S. Advances in Eating Disorders. J Clin Med 2020; 9:jcm9124047. [PMID: 33333763 PMCID: PMC7765238 DOI: 10.3390/jcm9124047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/11/2020] [Indexed: 11/16/2022] Open
Abstract
Eating disorders (EDs) are a group of mental disorders characterized by an altered food intake and the presence of inappropriate behaviors for the control of body weight, framed as an excessive concern regarding one’s weight and figure [...]
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Affiliation(s)
- Zaida Agüera
- CIBER Fisiopatología Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 08907 Barcelona, Spain
- Department of Psychiatry, University Hospital of Bellvitge-IDIBELL, 08907 Barcelona, Spain
- Department of Public Health, Mental Health and Perinatal Nursing, School of Nursing, University of Barcelona, 08907 Barcelona, Spain
- Correspondence: (Z.A.); (S.J.-M.); Tel.: +34-932607227 (Z.A.); +34-932607988 (S.J.-M.)
| | - Susana Jiménez-Murcia
- CIBER Fisiopatología Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 08907 Barcelona, Spain
- Department of Psychiatry, University Hospital of Bellvitge-IDIBELL, 08907 Barcelona, Spain
- Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, 08907 Barcelona, Spain
- Correspondence: (Z.A.); (S.J.-M.); Tel.: +34-932607227 (Z.A.); +34-932607988 (S.J.-M.)
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21
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Duriez P, Bou Khalil R, Chamoun Y, Maatoug R, Strumila R, Seneque M, Gorwood P, Courtet P, Guillaume S. Brain Stimulation in Eating Disorders: State of the Art and Future Perspectives. J Clin Med 2020; 9:E2358. [PMID: 32717984 PMCID: PMC7465000 DOI: 10.3390/jcm9082358] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/06/2020] [Accepted: 07/20/2020] [Indexed: 12/13/2022] Open
Abstract
The management of eating disorders (EDs) is still difficult and few treatments are effective. Recently, several studies have described the important contribution of non-invasive brain stimulation (repetitive transcranial magnetic stimulation, transcranial direct current stimulation, and electroconvulsive therapy) and invasive brain stimulation (deep brain stimulation and vagal nerve stimulation) for ED management. This review summarizes the available evidence supporting the use of brain stimulation in ED. All published studies on brain stimulation in ED as well as ongoing trials registered at clinicaltrials.gov were examined. Articles on neuromodulation research and perspective articles were also included. This analysis indicates that brain stimulation in EDs is still in its infancy. Literature data consist mainly of case reports, cases series, open studies, and only a few randomized controlled trials. Consequently, the evidence supporting the use of brain stimulation in EDs remains weak. Finally, this review discusses future directions in this research domain (e.g., sites of modulation, how to enhance neuromodulation efficacy, personalized protocols).
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Affiliation(s)
- Philibert Duriez
- GHU Paris Psychiatry and Neuroscience, Clinique des Maladies Mentales et de l’Encéphale (CMME), Sainte-Anne Hospital, 75014 Paris, France; (P.D.); (P.G.)
- Institute of Psychiatry and Neurosciences of Paris (IPNP), UMR_S1266, INSERM, Université de Paris, 102-108 rue de la Santé, 75014 Paris, France
| | - Rami Bou Khalil
- Department of Psychiatry, Hotel Dieu de France- Saint Joseph University, 166830 Beirut, Lebanon; (R.B.K.); (Y.C.)
- Neuropsychiatry: Epidemiological and Clinical Research, Université Montpellier, INSERM, CHU de Montpellier, 34295 Montpellier, France; (M.S.); (P.C.)
| | - Yara Chamoun
- Department of Psychiatry, Hotel Dieu de France- Saint Joseph University, 166830 Beirut, Lebanon; (R.B.K.); (Y.C.)
| | - Redwan Maatoug
- Sorbonne Université, AP-HP, Service de Psychiatrie Adulte de la Pitié-Salpêtrière, Institut du Cerveau, ICM, 75013 Paris, France;
| | - Robertas Strumila
- Faculty of Medicine, Institute of Clinical Medicine, Psychiatric Clinic, Vilnius University, 03101 Vilnius, Lithuania;
| | - Maude Seneque
- Neuropsychiatry: Epidemiological and Clinical Research, Université Montpellier, INSERM, CHU de Montpellier, 34295 Montpellier, France; (M.S.); (P.C.)
- Department of Emergency Psychiatry and Post-Acute Care, CHRU Montpellier, 34295 Montpellier, France
| | - Philip Gorwood
- GHU Paris Psychiatry and Neuroscience, Clinique des Maladies Mentales et de l’Encéphale (CMME), Sainte-Anne Hospital, 75014 Paris, France; (P.D.); (P.G.)
- Institute of Psychiatry and Neurosciences of Paris (IPNP), UMR_S1266, INSERM, Université de Paris, 102-108 rue de la Santé, 75014 Paris, France
| | - Philippe Courtet
- Neuropsychiatry: Epidemiological and Clinical Research, Université Montpellier, INSERM, CHU de Montpellier, 34295 Montpellier, France; (M.S.); (P.C.)
- Department of Emergency Psychiatry and Post-Acute Care, CHRU Montpellier, 34295 Montpellier, France
| | - Sébastien Guillaume
- Neuropsychiatry: Epidemiological and Clinical Research, Université Montpellier, INSERM, CHU de Montpellier, 34295 Montpellier, France; (M.S.); (P.C.)
- Department of Emergency Psychiatry and Post-Acute Care, CHRU Montpellier, 34295 Montpellier, France
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