Posts tagged eating disorders
Posts tagged eating disorders
A mild electrical stimulation to a specific brain area could be an effective treatment for some patients with eating disorders such as bulimia, who suffer from episodes of severe binge eating and purging behaviors, researchers say.
After one 42-year-old woman received the electrical stimulation, called transcranial magnetic stimulation (TMS), as a treatment for her depression, and showed an unexpected recovery from her 20-year battle against bulimia nervosa, her doctors conducted a pilot study to see whether the treatment would also work for other patients with eating disorders, said Dr. Jonathan Downar, of the University of Toronto. Downar described the study Tuesday (Nov. 12) here at the annual meeting of the Society for Neuroscience.
In the study, Downar and his colleagues recruited 20 patients with bulimia and stimulated a part of their frontal lobes called the dorsomedial prefrontal cortex, which is next to the brain region usually stimulated for treating depression. The patients, who had already tried conventional therapies and medications but had seen no improvement, received 20 sessions of electrical stimulation daily for four weeks.
At the end of the treatment, six of the patients saw their binge eating and purging symptoms almost completely disappear. In another four patients, symptoms improved by more than 50 percent. Eight patients saw only little improvement, and two got worse, Downar said.
Although larger studies and clinical trials are needed to confirm the results of the pilot study, Downar said he is optimistic about the promise of using TMS for treating certain patients with eating disorders.
"There are lots of things you could do to treat disorders like depression, but for these folks [with bulimia], there’s really nothing if they have gone through all of the medications" and therapy options, Downar said.
Eating disorders, such as anorexia and bulimia, affect more than 8 million people in North America. These disorders often carry emotional distress, disrupt the person’s normal life and can even lead to life-threatening medical problems.
TMS is a relatively new technique, and involves a large electromagnetic coil that is placed over the skull, and changes the activity in a targeted brain region by inducing electric currents. Although the change is temporary and reversible, with repeated stimulation, doctors can create lasting changes in neuronal activity. Repeated TMS has been approved by the U.S. Food and Drug Administration as a treatment for some forms of depression.
In the study, the researchers used brain imaging to examine whether differences in brain activity could explain why some patients respond well to TMS treatment while others show little or no improvement.
They found that before the treatment, responders had lower connectivity between the frontal lobe and a set of brain areas (such as the striatum) that are linked to rewards and cravings. This low connectivity could be a sign of impulsiveness, and stimulation may have helped to make the missing connection in these patients’ brains, Downar said.
In contrast, the brains of the people whose bulimia was not helped by TMS appeared more connected in those areas. In these patients, TMS appears to be ineffective in treating bulimia because the brain stimulation is “giving them something they don’t need, because they already have it,” Downar said.
The brain imaging results suggest that doctors may be able to identify which patients will respond to TMS treatment, and spare others from a weeks-long treatment.
"By using brain imaging to detect these patterns, we may eventually be able to predict which patients are most likely to benefit," Downar said.
A growing body of evidence shows the impact of diet on brain function, and identifies patterns of brain activity associated with eating disorders such as binge eating and purging. The findings were presented at Neuroscience 2013, the annual meeting of the Society for Neuroscience and the world’s largest source of emerging news about brain science and health.
Millions of people worldwide suffer from eating disorders such as anorexia, bulimia, and binge eating. With increased risk for psychiatric and chronic diseases, today’s studies are valuable in helping generate new strategies to treat disorders from obesity to anorexia.
Today’s new findings show that:
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“As scientists uncover the impacts of diet on brain function, the adage ‘You are what you eat,’ takes on new meaning,” said press conference moderator Fernando Gomez-Pinilla, PhD, of the University of California, Los Angeles, an expert in the impact of the environment on brain health. “We cannot separate the nutritional benefits of food for the body from that of the mind. What we put into the body also shapes the brain, for better or for worse.”
Eating disorders like anorexia nervosa and bulimia often run in families, but identifying specific genes that increase a person’s risk for these complex disorders has proved difficult.
Now scientists from the University of Iowa and University of Texas Southwestern Medical Center have discovered—by studying the genetics of two families severely affected by eating disorders—two gene mutations, one in each family, that are associated with increased risk of developing eating disorders.
Moreover, the new study shows that the two genes interact in the same signaling pathway in the brain, and that the two mutations produce the same biological effect. The findings suggest that this pathway might represent a new target for understanding and potentially treating eating disorders.
"If you’re considering two randomly discovered genes, the chance that they will interact is small. But, what really sealed the deal for us that the association was real was that the mutations have the same effect," says Michael Lutter, UI assistant professor of psychiatry and senior author of the study.
Overall, the study, published Oct. 8 in the Journal of Clinical Investigation, suggests that mutations that decrease the activity of a transcription factor—a protein that turns on the expression of other genes—called estrogen-related receptor alpha (ESRRA) increase the risk of eating disorders.
The challenge of finding genes for complex diseases
Anorexia nervosa and bulimia nervosa are fairly common, especially among women. They affect between 1 and 3 percent of women. They also are among the most lethal of all psychiatric diseases; about 1 in 1,000 women will die from anorexia.
Finding genes associated with complex diseases like eating disorders is challenging. Scientists can analyze the genetics of thousands of people and use statistics to find common, low-risk gene variations, the accumulation of which causes complex disorders from psychiatric conditions like eating disorders to conditions like heart disease or obesity.
On the other end of the spectrum are very rare gene variants, which confer an almost 100 percent risk of getting the disease. To track down these variants, researchers turn to large families that are severely affected by an illness.
Lutter and his colleagues were able to work with two such families to identify the two new genes associated with eating disorders.
"It’s basically a matter of finding out what the people with the disorder share in common that people without the disease don’t have," Lutter explains. "From a theoretical perspective, it’s straightforward. But the difficulty comes in having a large enough group to find these rare genes. You have to have large families to get the statistical power."
In the new study, 20 members from three generations of one family (10 affected individuals and 10 unaffected), and eight members of a second family (six affected and two unaffected) were analyzed.
Two genes, one pathway
The gene discovered in the larger family was ESRRA, a transcription factor that turns on the expression of other genes. The mutation associated with eating disorders decreases ESSRA activity.
The gene found in the second family is a transcriptional repressor called histone deacetylase 4 (HDAC4), which turns off transcription factors, including ESRRA. This mutation is unusual in the sense that it increases the gene’s activity—most mutations decrease or destroy a gene’s activity.
Importantly, the team also found that the two affected proteins interacted with one another; HDAC4 binds to ESRRA and inhibits it.
"The fact that the HDAC4 mutation happens to increase the gene activity and happens to increase its ability to repress the ESSRA protein we found in the other family was just beyond coincidence," Lutter says.
The two genes are already known to be involved in metabolic pathways in muscle and fat tissue. They also are both regulated by exercise.
In the brain, HDAC4 is very important for regulating genes that form connections between neurons. However, there’s almost nothing known about ESRRA in the brain, although it is expressed in many brain regions that are disrupted in anorexia.
Lutter and his colleagues plan to study the role of these genes in mice and in cultured neurons to find out exactly what they are doing in the brain. They will also look for ways to modify the genes’ activity, with the long-term goal of finding small molecules that might be developed into therapies for eating disorders.
They also plan to study patients with eating disorders and see if other genes associated with the ESSRA/HDAC4 brain pathway are affected in humans.
The finding shows that certain parts of brain cells could play a critical role in anorexia, bulimia, binge eating disorder, and obesity.
Sixty years ago scientists could electrically stimulate a region of a mouse’s brain causing the mouse to eat, whether hungry or not. Now researchers from UNC School of Medicine have pinpointed the precise cellular connections responsible for triggering that behavior. The finding, published September 27 in the journal Science, lends insight into a cause for obesity and could lead to treatments for anorexia, bulimia nervosa, and binge eating disorder, the most prevalent eating disorder in the United States.
“The study underscores that obesity and other eating disorders have a neurological basis,” said senior study author Garret Stuber, PhD, assistant professor in the department of psychiatry and department of cell biology and physiology. He’s also a member of the UNC Neuroscience Center. “With further study, we could figure out how to regulate the activity of cells in a specific region of the brain and develop treatments.”
Cynthia Bulik, PhD, Distinguished Professor of Eating Disorders at UNC School of Medicine and the Gillings School of Global Public Health, said, “Stuber’s work drills down to the precise biological mechanisms that drive binge eating and will lead us away from stigmatizing explanations that invoke blame and a lack of willpower.” Bulik was not part of the research team.
Back in the 1950s, when scientists electrically stimulated a region of the brain called the lateral hypothalamus, they knew that they were stimulating many different types of brain cells. Stuber wanted to focus on one cell type — gaba neurons in the bed nucleus of the stria terminalis, or BNST. The BNST is an outcropping of the amygdala, the part of the brain associated with emotion. The BNST also forms a bridge between the amygdala and the lateral hypothalamus, the brain region that drives primal functions such as eating, sexual behavior, and aggression.
The BNST gaba neurons have a cell body and a long strand with branched synapses that transmit electrical signals into the lateral hypothalamus. Stuber and his team wanted to stimulate those synapses by using an optogenetic technique, an involved process that would let him stimulate BNST cells simply by shining light on their synapses.
Typically, brain cells don’t respond to light. So Stuber’s team used genetically engineered proteins — from algae — that are sensitive to light and used genetically engineered viruses to deliver them into the brains of mice. Those proteins then get expressed only in the BNST cells, including in the synapses that connect to the hypothalamus.
His team then implanted fiber optic cables in the brains of these specially-bred mice, and this allowed the researchers to shine light through the cables and onto BNST synapses. As soon as the light hit BNST synapses the mice began to eat voraciously even though they had already been well fed. Moreover, the mice showed a strong preference for high-fat foods.
“They would essentially eat up to half their daily caloric intake in about 20 minutes,” Stuber said. “This suggests that this BNST pathway could play a role in food consumption and pathological conditions such as binge eating.”
Stimulating the BNST also led the mice to exhibit behaviors associated with reward, suggesting that shining light on BNST cells enhanced the pleasure of eating. On the flip side, shutting down the BNST pathway caused mice to show little interest in eating, even if they had been deprived of food.
“We were able to really home in on the precise neural circuit connection that was causing this phenomenon that’s been observed for more than 50 years,” Stuber said.
The study, which uses technologies highlighted in the new National Institutes of Health Brain Initiative, suggests that faulty wiring in BNST cells could interfere with hunger or satiety cues and contribute to human eating disorders, leading people to eat even when they are full or to avoid food when they are hungry. Further research is needed to determine whether it would be possible to develop drugs that correct a malfunctioning BNST circuit.
“We want to actually observe the normal function of these cell types and how they fire electrical signals when the animals are feeding or hungry,” Stuber said. “We want to understand their genetic characteristics – what genes are expressed. For example, if we find cells that become really activated after binge eating, can we look at the gene expression profile to find out what makes those cells unique from other neurons.”
And that, Stuber said, could lead to potential targets for drugs to treat certain populations of patients with eating disorders.
New research indicates that teens with anorexia nervosa have bigger brains than teens that do not have the eating disorder. That is according to a study by researchers at the University of Colorado’s School of Medicine that examined a group of adolescents with anorexia nervosa and a group without. They found that girls with anorexia nervosa had a larger insula, a part of the brain that is active when we taste food, and a larger orbitofrontal cortex, a part of the brain that tells a person when to stop eating.
Guido Frank, MD, assistant professor of psychiatry and neuroscience at CU School of Medicine, and his colleagues report that the bigger brain may be the reason people with anorexia are able to starve themselves. Similar results in children with anorexia nervosa and in adults who had recovered from the disease, raise the possibility that insula and orbitofrontal cortex brain size could predispose a person to develop eating disorders.
"While eating disorders are often triggered by the environment, there are most likely biological mechanisms that have to come together for an individual to develop an eating disorder such as anorexia nervosa," Frank says.
The researchers recruited 19 adolescent girls with anorexia nervosa and 22 in a control group and used magnetic resonance imaging (MRI) to study brain volumes. Individuals with anorexia nervosa showed greater left orbitofrontal, right insular, and bilateral temporal cortex gray matter compared to the control group. In individuals with anorexia nervosa, orbitofrontal gray matter volume related negatively with sweet tastes. An additional comparison of this study group with adults with anorexia nervosa and a healthy control group supported greater orbitofrontal cortex and insula volumes in the disorder across this age group as well.
The medial orbitofrontal cortex has been associated with signaling when we feel satiated by a certain type of food (so called “sensory specific satiety”). This study suggests that larger volume in this brain area could be a trait across eating disorders that promotes these individuals to stop eating faster than in healthy individuals, before eating enough.
The right insula is a region that processes taste, as well as integrates body perception and this could contribute to the perception of being fat despite being underweight.
This study is complementary to another that found adults with anorexia and individuals who had recovered from this illness also had differences in brain size, previously published in the American Journal of Psychiatry.
Neuroimaging improves understanding of eating disorder
In a spacious hotel room not far from the beach in La Jolla, Calif., Kelsey Heenan gripped her fiancé’s hand. Heenan, a 20-year-old anorexic woman, couldn’t believe what she was hearing. Walter Kaye, director of the eating disorders program at the University of California, San Diego, was telling a handful of rapt patients and their family members what the latest brain imaging research suggested about their disorder.
It’s not your fault, he told them.
Heenan had always assumed that she was to blame for her illness. Kaye’s data told a different story. He handed out a pile of black-and-white brain scans — some showed the brains of healthy people, others were from people with anorexia nervosa. The scans didn’t look the same. “People were shocked,” Heenan says. But above all, she remembers, the group seemed to sigh in relief, breathing out years of buried guilt about the disorder. “It’s something in the way I was wired — it’s something I didn’t choose to do,” Heenan says. “It was pretty freeing to know that there could be something else going on.”
Years of psychological and behavioral research have helped scientists better understand some signs and triggers of anorexia. But that knowledge hasn’t straightened out the disorder’s tangled roots, or pointed scientists to a therapy that works for everyone. “Anorexia has a high death rate, it’s expensive to treat and people are chronically ill,” says Kaye.
Kaye’s program uses a therapy called family-based treatment, or FBT, to teach adolescents and their families how to manage anorexia. A year after therapy, about half of the patients treated with FBT recover. In the world of eating disorders, that’s success: FBT is considered one of the very best treatments doctors have. To many scientists, that just highlights how much about anorexia remains unknown.
Kaye and others are looking to the brain for answers. Using brain imaging tools and other methods to explore what’s going on in patients’ minds, researchers have scraped together clues that suggest anorexics are wired differently than healthy people. The mental brakes people use to curb impulsive instincts, for example, might get jammed in people with anorexia. Some studies suggest that just a taste of sugar can send parts of the brain barrelling into overdrive. Other brain areas appear numb to tastes — and even sensations such as pain. For people with anorexia, a sharp pang of hunger might register instead as a dull thud.
The mishmash of different brain imaging data is just beginning to highlight the neural roots of anorexia, Kaye says. But because starvation physically changes the brain, researchers can run into trouble teasing out whether glitchy brain wiring causes anorexia, or vice versa. Still, Kaye thinks understanding what’s going on in the brain may spark new treatment ideas. It may also help the eating disorder shake off some of its noxious stereotypes.
“One of the biggest problems is that people do not take this disease seriously,” says James Lock, an eating disorders researcher at Stanford University who cowrote the book on family-based treatment. “No one gets upset at a child who has cancer,” he says. “If the treatment is hard, parents still do it because they know they need to do it to make their child well.”
Pop culture often paints anorexics as willful young women who go on diets to be beautiful, he says. But, “you can’t just choose to be anorexic,” Lock adds. “The brain data may help counteract some of the mythology.”
A society that glamorizes thinness can encourage unhealthy eating behaviors in kids, scientists have shown. A 2011 study of Minnesota high school students reported that more than half of girls had dieted within the past year. Just under a sixth had used diet pills, vomiting, laxatives or diuretics.
But a true eating disorder goes well beyond an unhealthy diet. Anorexia involves malnutrition, excessive weight loss and often faulty thinking about one of the body’s most basic drives: hunger. The disorder is also rare. Less than 1 percent of girls develop anorexia. The disease crops up in boys too, but adolescent girls — especially in wealthy countries such as the U.S., Australia and Japan — are most likely to suffer from the illness.
As the disease progresses, people with anorexia become intensely afraid of getting fat and stick to extreme diets or exercise schedules to drop pounds. They also misjudge their own weight. Beyond these diagnostic hallmarks, patients’ symptoms can vary. Some refuse to eat, others binge and purge. Some live for years with the illness, others yo-yo between weight gain and loss. Though most anorexics gain back some weight within five years of becoming ill, anorexia is the deadliest of all mental disorders.
Though anorexia tends to run in families, scientists haven’t yet hammered out the suite of genes at play. Some individuals are particularly vulnerable to developing an eating disorder. In these people, stressful life changes, such as heading off to college, can tip the mental scales toward anorexia.
For decades, scientists have known that anorexic children behave a little differently. In school and sports, anorexic kids strive for perfection. Though Heenan, a former college basketball player, didn’t notice her symptoms creeping in until the end of high school, she remembers initiating strict practice regimens as a child. Starting in second grade, Heenan spent hours perfecting her jump shot, shooting the ball again and again until she had the technique exactly right — until her form was flawless.
“It’s very rare for me to see a person with anorexia in my office who isn’t a straight-A student,” Lock says. Even at an early age, people who later develop the eating disorder tend to exert an almost superhuman ability to practice, focus or study. “They will work and work and work,” says Lock. “The problem is they don’t know when to stop.”
In fact, many scientists think anorexics’ brains might be wired for willpower, for good and ill. Using new imaging tools that let scientists watch as a person’s mental gears grind through different tasks, researchers are starting to pin down how anorexic brains work overtime.
Different wiring: Studies of the brains of people with anorexia have revealed a number of complex brain circuits that show changes in activity compared with healthy people. Medical RF, adapted by M. Atarod
To glimpse the circuits that govern self-control, experimental neuropsychologist Samantha Brooks uses functional magnetic resonance imaging, or fMRI, a tool that measures and maps brain activity. Last year, she and colleagues scanned volunteers as they imagined eating high-calorie foods, such as chocolate cake and French fries, or using inedible objects such as clothespins piled on a plate. One result gave Brooks a jolt. A center of self-control in anorexics’ brains sprung to life when the volunteers thought about food — but only in the women who severely restricted their calories, her team reported March 2012 in PLOS ONE.
The control center, two golf ball–sized chunks of tissue called the dorsolateral prefrontal cortex, or DLPFC, helps stamp out primitive urges. “They put a brake on your impulsive behaviors,” says Brooks, now at the University of Cape Town in South Africa.
For Brooks, discovering the DLPFC data was like finding a tiny vein of gold in a heap of granite. The control center could be the nugget that reveals how anorexics clamp down on their appetites. So she and her colleagues devised an experiment to test anorexics’ DLPFC. Using a memory task known to engage the brain region, the researchers quizzed volunteers while showing them subliminal images. The quizzes tested working memory, the mental tool that lets people hold phone numbers in their heads while hunting for a pen and paper. Compared with healthy people, anorexics tended to get more answers right, Brooks’ team wrote June 2012 in Consciousness and Cognition. “The patients were really good,” Brooks says. “They hardly made any mistakes.”
A turbocharged working memory could help anorexics hold on to rules they set for themselves about food. “It’s like saying ‘I will only eat a salad at noon, I will only eat a salad at noon,’ over and over in your mind,” says Brooks. These mantras may become so ingrained that an anorexic person can’t escape them.
But looking at subliminal images of food distracted anorexics from the memory task. “Then they did just as well as the healthy people,” Brooks says. The results suggest that anorexic people might tap into their DLPFC control circuits when faced with food.
James Lock has also seen signs of self-control circuits gone awry in people with eating disorders. In 2011, he and colleagues scanned the brains of teenagers with different eating disorders while signaling them to push a button. While volunteers lay inside the fMRI machine, researchers flashed pictures of different letters on an interior screen. For every letter but “X,” Lock’s group told the teens to push a button. During the task, anorexic teens who obsessively cut calories tended to have more active visual circuits than healthy teens or those with bulimia, a disorder that compels people to binge and purge. The result isn’t easy to explain, says Lock. “Anorexics may just be more focused in on the task.”
Bulimics’ brains told a simpler story. When teens with bulimia saw the letter “X,” broad swaths of their brains danced with activity — more so than the healthy or calorie-cutting anorexic volunteers, Lock’s team reported in the American Journal of Psychiatry. For bulimics, controlling the impulse to push the button may take more brain power than for others, Lock says.
Though the data don’t reveal differences in self-control between anorexics and healthy people, Lock thinks that anorexics’ well-documented ability to swat away urges probably does have signatures in the brain. He notes that his study was small, and that the “healthy” people he used as a control group might have shared similarities with anorexics. “The people who tend to volunteer are generally pretty high performers,” he says. “The chances are good that my controls are a little bit more like anorexics than bulimics.”
Still, Lock’s results offered another flicker of proof that people with eating disorders might have glitches in their self-control circuits. A tight rein on urges could help steer anorexics toward illness, but the parts of their brain tuned into rewards, such as sugary snacks, may also be a little off track.
When an anorexic woman unexpectedly gets a taste of sugar (yellow) or misses out on it (blue), her brain’s reward circuitry shows more activity than a healthy-weight or obese woman’s. Anorexics’ reward-processing systems may be out of order. Credit: G. Frank et al/ Neuropsychopharmacology 2012
For many anorexics, food just doesn’t taste very good. A classic symptom of the disorder is anhedonia, or trouble experiencing pleasure. Parts of Heenan’s past reflect the symptom. When she was ill, she had trouble remembering favorite dishes from childhood, for example — a blank spot common to anorexics. “I think I enjoyed some things,” she says. Beyond frozen yogurt, she can’t really rattle off a list.
After Heenan started seriously restricting her calories in college, only one aspect of food made her feel satisfied. Skipping, rather than eating, meals felt good, she says. Some of Heenan’s symptoms may have stemmed from frays in her reward wiring, the brain circuitry connecting food to pleasure. In the past few years, researchers have found that the chemicals coursing through healthy people’s reward circuits aren’t quite the same in anorexics. And studies in rodents have linked chemical changes in reward circuitry to under- and overeating.
To find out whether under- and overweight people had altered brain chemistry, eating disorder researcher Guido Frank of the University of Colorado Denver studied anorexic, healthy-weight and obese women. He and his colleagues trained volunteers to link images, such as orange or purple shapes, with the taste of a sweet solution, slightly salty water or no liquid. Then, the researchers scanned the women’s brains while showing them the shapes and dispensing tiny squirts of flavors. But the team threw in a twist: Sometimes the flavors didn’t match up with the right images.
When anorexics got an unexpected hit of sugar, a surge of activity bloomed in their brains. Obese people had the opposite response: Their brains didn’t register the surprise. Healthy-weight women fit somewhere in the middle, Frank’s team reported August 2012, in Neuropsychopharmacology. While obese people might not be sensitive to sweets anymore, a little sugar rush goes a long way for anorexics. “It’s just too much stimulation for them,” Frank says.
One of the lively regions in anorexics’ brains was the ventral striatum, a lump of nerve cells that’s part of a person’s reward circuitry. The lump picks up signals from dopamine, a chemical that rushes in when most people see a sugary treat.
Frank says that it’s possible cutting calories could sculpt a person’s brain chemistry, but he thinks some young people are just more likely to become sugar-sensitive than others. Frank suspects anorexics’ dopamine-sensing equipment might be out of alignment to begin with. And he may be onto something. Recently, researchers in Kaye’s lab at UCSD showed that the same chemical that makes people perk up when a coworker brings in a box of doughnuts might actually trigger anxiety in anorexics.
Usually a rush of dopamine triggers euphoria or a boost of energy, says Ursula Bailer, a psychiatrist and neuroimaging researcher at UCSD. Anorexics don’t seem to pick up those good feelings.
When Bailer and colleagues gave volunteers amphetamine, a drug known to trigger dopamine release, and then asked them to rate their feelings, healthy people stuck to a familiar script. The drug made them feel intensely happy, Bailer’s team described March 2012 in the International Journal of Eating Disorders. Researchers linked the volunteers’ happy feelings to a wave of dopamine flooding the brain, using an imaging technique to track the chemical’s levels.
But anorexics said something different. “People with anorexia didn’t feel euphoria — they got anxious,” Bailer says. And the more dopamine coursing through anorexics’ brains, the more anxious they felt. Anorexics’ reaction to the chemical could help explain why they steer clear of food — or at least foods that healthy people find tempting. “Anorexics don’t usually get anxious if you give them a plate of cucumbers,” Bailer says.
Beyond the anxiety finding, one other aspect of the study sticks out: Instead of examining sick patients, Bailer, Kaye and colleagues recruited women who had recovered from anorexia. By studying people whose brains are no longer starving, Kaye’s team hopes to sidestep the chicken-and-egg question of whether specific brain signatures predispose people to anorexia or whether anorexia carves those signatures in the brain.
Though Kaye says that there’s still a lot scientists don’t know about anorexia, he’s convinced it’s a disorder that starts in the brain. Compared with healthy children, anorexic children’s brains are getting different signals, he says. “Parents have to realize that it’s very hard for these kids to change.”
Kaye thinks imaging data can help families reframe their beliefs about anorexia, which might help them handle tough treatments. He thinks the data can also offer new insights into therapies tailored for anorexics’ specific traits.
One trait Kaye has focused on is anorexics’ sense of awareness of their bodies. Peel back the outer lobes of the brain by the temples, and the bit that handles body awareness pops into view. These regions, little islands of tissue called the insula, are one of the first brain areas to register pain, taste and other sensations. When people hold their breath, for example, and feel the panicky claws of air hunger, “the insula lights up like crazy,” Kaye says.
Kaye and colleagues have shown that the insulas of people with anorexia seem to be somewhat dulled to sensations. In a recent study, his team strapped heat-delivering gadgets to volunteers’ arms and cranked the devices to painfully hot temperatures while measuring insula activity via fMRI.
Compared with healthy volunteers, bits of recovered anorexics’ insulas dimmed when the researchers turned up the heat. But when researchers simply warned that pain was coming, other parts of the brain region flared brightly, Kaye’s team reported in January in the International Journal of Eating Disorders. For people who have had anorexia, actually feeling pain didn’t seem as bad as anticipating it. “They don’t seem to be sensing things correctly,” says Kaye.
If anorexics can’t detect sensations like pain properly, they may also have trouble picking up other signals from the body, such as hunger. Typically when people get hungry, their insulas rev up to let them know. And in healthy hungry people, a taste of sugar really gets the insula excited. For anorexics, this hunger-sensing part of the brain seems numb. Parts of the insula barely perked up when recovered anorexic volunteers tasted sugar, Kaye’s team showed this June in the American Journal of Psychiatry. The findings “may help us understand why people can starve themselves and not get hungry,” Kaye says.
Though the brain region that tells people they’re hungry might have trouble detecting sweet signals, some reward circuits seem to overreact to the same cues. Combined with a tendency to swap happiness for anxiety, and a mental vise grip on behavior, anorexics might have just enough snags in their brain wiring to tip them toward disease.
Now, Kaye’s group hopes to tap neuroimaging data for new treatment ideas. One day, he thinks doctors might be able to help anorexics “train” their insulas using biofeedback. With real-time brain scanning, patients could watch as their insulas struggle to pick up sugar signals, and then practice strengthening the response. More effective treatment options could potentially spare anorexics the relapses many patients suffer.
Heenan says she’s one of the lucky ones. Four years have passed since she first saw the anorexic brain images at UCSD. In the months following her treatment, Heenan and her family worked together to rebuild her relationship with food. At first, her fiancé picked out all her meals, but step by step, Heenan earned autonomy over her diet. Today, Heenan, a coordinator for Minneapolis’ public schools, is married and has a new puppy. “Life can be good,” she says. “Life can be fun. I want other people to know the freedom that I do.”
Searching for treatments
The bowl of pasta sitting in front of Kelsey Heenan didn’t look especially scary.
Spaghetti, chopped asparagus and chunks of chicken glistened in an olive oil sauce. Usually, such savory fare might make a person’s mouth water. But when Heenan’s fiancé served her a portion, she started sobbing. “You can’t do this to me,” she told him. “I thought you loved me!”
Heenan was confronting her “fear foods” at the Eating Disorders Center for Treatment and Research at UCSD. Therapists in her treatment program, Intensive Multi-Family Therapy, spend five days teaching anorexic patients and families about the disorder and how to encourage healthy eating. “There’s no blame,” says Christina Wierenga, a clinical neuropsychologist at UCSD. “The focus is just on having the parent refeed the child.” Therapists lay out healthy meals and portion sizes for teens, bolster parents’ self-confidence and hammer home the dangers of not eating. Heenan compares the experience to boot camp. But by the end of her time at the center, she says, “I was starting to see glimpses of what life could be like as a healthy person.”
Treatment options for anorexia include a broad mix of behavioral and medication-based therapies. Most don’t work very well, and many lack the support of evidence-based trials. Hospitalizing patients can boost short-term weight gain, “but when people go home they lose all the weight again,” says Stanford University’s James Lock, one of the architects of family-based treatment. That treatment is currently considered the most effective therapy for adolescent anorexics.
In a 2010 clinical trial, half of teens who underwent FBT maintained a normal weight a year after therapy. In contrast, only a fifth of teens treated with adolescent-focused individual therapy, which aims to help kids cope with emotions without using starvation, hit the healthy weight goal.
Few good options exist for adult anorexics, a group notorious for dropping out of therapy. New work hints that cognitive remediation therapy, or CRT, which uses cognitive exercises to change anorexics’ behaviors, has potential. After two months of CRT, only 13 percent of patients abandoned treatment, and most regained some weight, Lock and colleagues reported in the April International Journal of Eating Disorders. Researchers still need to find out, however, if CRT helps patients keep weight on long-term.
Findings may have implications for treating compulsive behavior associated with psychiatric disease and eating disorders
What started as an experiment to probe brain circuits involved in compulsive behavior has revealed a surprising connection with obesity.
The University of Iowa-led researchers bred mice missing a gene known to cause obesity, and suspected to also be involved in compulsive behavior, with a genetic mouse model of compulsive grooming. The unexpected result was offspring that were neither compulsive groomers nor obese.
The study, published the week of June 10 in the online early edition of the Proceedings of the National Academy of Sciences (PNAS), suggests that the brain circuits that control obsessive-compulsive behavior are intertwined with circuits that control food intake and body weight. The findings have implications for treating compulsive behavior, which is associated with many forms of psychiatric disease, including obsessive-compulsive disorder (OCD), Tourette syndrome, and eating disorders.
UI neuro-psychiatrists Michael Lutter, M.D., Ph.D. and Andrew Pieper, M.D., Ph.D. led the study. The team also included researchers from Stanford University School of Medicine, University of Texas Southwestern Medical Center, Beth Israel Deaconess Medical Center, and Harvard Medical School.
Lutter, an assistant professor of psychiatry, and Pieper, an associate professor of psychiatry and neurology at the UI Carver College of Medicine, both recently arrived at the UI and use mouse models in their laboratories to study human disorders and conditions.
Pieper is interested in compulsive behavior. His mouse model of compulsivity lacks a brain protein called SAPAP3. These mice groom themselves excessively to the point of lesioning their skin, and their compulsive behavior can be effectively treated by fluoxetine, a drug that is commonly used to treat OCD in people.
Lutter works with a mouse that genetically mimics an inherited form of human obesity. This mouse lacks a brain protein known a MC4R. Mutations in the MC4R gene are the most common single-gene cause of morbid obesity and over-eating in people.
“I study MC4R signaling pathways and their involvement in the development of obesity,” Lutter explains. “I’m also interested in how these same molecules affect mood and anxiety and reward, because it’s known that there is a connection between depression and anxiety and development of obesity.”
An old study hinted that in addition to its role in food intake and obesity, MC4R might also play a role in compulsive behavior, which got Lutter and Pieper thinking of ways to test the possible interaction.
"We knew in one mouse you could stimulate excessive grooming through this MC4R pathway and in another mouse a different pathway (SAPAP3) caused compulsive grooming," Lutter says. "So, we decided to breed the two mice together to see if it would have an effect on compulsive grooming."
The experiment proved their original hypothesis—knocking out the MC4R protein in the OCD mouse normalized grooming behavior in the animals. In addition, chemically blocking MC4R in the OCD mice also eliminated compulsive grooming. The rescued behavior is mirrored by normalization of a particular pattern of brain cell communication linked to compulsive behavior.
However, the breeding experiment revealed another totally unexpected result. Loss of the SAPAP3 protein from the mice that were obese due to lack of MC4R produced mice of normal weight.
"We had this other, completely shocking finding—we completely rescued body weight and food intake in the double null mouse," Lutter says. "So, not only were we affecting the brain regions involved in grooming and behavior, but we also affected the brain regions involved in food intake and body weight."
Although obesity and obsessive-compulsive behavior may seem unrelated, Lutter suggests that the connection may be rooted in the evolutionary need to eat safe, clean food in times of a food abundance, and to lessen this drive when food is scarce.
"Food safety has been an issue through the entire course of human evolution—refrigeration is a relatively recent invention," he says. "Obsessive behavior, or fear of contamination, may be an evolutionary protection against eating rotten food."
Oils and fats have lots of calories and nutrients but they also spoil much more easily than less nutrient- and calorie-dense foods like potatoes, onions, or apples.
"I think this circuit that we have uncovered is probably involved in determining whether or not people should eat calorically dense foods," he says.
Lutter suggests that slight perturbations in this system might lead, on one hand, to disorders that link anxiety and obsessive behavior to limited food selection or intake, such as anorexia nervosa, Tourette syndrome, or OCD, and on the other hand, to obesity, where people over-consume high-fat foods and may have decreased obsessive behavior and anxiety.
“The next step will be to determine how these two pathways communicate with one another, in hopes of identifying new ways to develop drugs to treat either of these disorders,” says Pieper.
In a world first, a team of researchers at the Krembil Neuroscience Centre and the University Health Network have shown that Deep Brain Stimulation (DBS) in patients with chronic, severe and treatment-resistant Anorexia Nervosa (anorexia) helps some patients achieve and maintain improvements in body weight, mood, and anxiety.
The results of this trial, entitled Deep Brain Stimulation of the Subcallosal Cingulate Area for Treatment-Refractory Anorexia Nervosa: A Phase I Pilot Trial, are published in the medical journal The Lancet. The study is a collaboration between lead author Dr. Nir Lipsman a neurosurgery resident at the University of Toronto and PhD student at the Krembil Neuroscience Centre; Dr. Andres Lozano, a neurosurgeon, at the Krembil Neuroscience Centre of Toronto Western Hospital and a professor and chairman of neurosurgery at the University of Toronto, whose research lab was instrumental in conducting the DBS research; and Dr. Blake Woodside, medical director of Canada’s largest eating disorders program at Toronto General Hospital and a professor of psychiatry at the University of Toronto.
The phase one safety trial investigated the procedure in six patients who would likely continue with a chronic illness and/or die a premature death because of the severity of their condition. The study’s participants had an average age of 38, and a mean duration of illness of 18 years. In addition to the anorexia, all patients, except one, also suffered from psychiatric conditions such as major depressive disorder and obsessive-compulsive disorder. At the time of the study, all patients currently, or had previously, suffered multiple medical complications related to their anorexia – altogether, the six patients had a history of close to 50 hospitalizations during their illnesses.
Study participants were treated with Deep Brain Stimulation (DBS), a neurosurgical procedure that moderates the activity of dysfunctional brain circuits. Neuroimaging has shown that there are both structural and functional differences between anorexia patients and healthy controls in brain circuits which regulate mood, anxiety, reward and body-perception.
Patients were awake when they underwent the procedure which implanted electrodes into a specific part of the brain involved with emotion, and found to be highly important in disorders such as depression. During the procedure, each electrode contact was stimulated to look for patient response of changes in mood, anxiety or adverse effects. Once implanted, the electrodes were connected to an implanted pulse generator below the right clavicle, much like a heart pacemaker.
Testing of patients was repeated at one, three, and six-month intervals after activation of the pulse generator device. After a nine-month period following surgery, the team observed that three of the six patients had achieved weight gain which was defined as a body-mass index (BMI) significantly greater than ever experienced by the patients. For these patients, this was the longest period of sustained weight gain since the onset of their illness. Furthermore, four of the six patients also experienced simultaneous changes in mood, anxiety, control over emotional responses, urges to binge and purge and other symptoms related to anorexia, such as obsessions and compulsions. As a result of these changes, two of these patients completed an inpatient eating disorders program for the first time in the course of their illness.
“We are truly ushering in a new of era of understanding of the brain and the role it can play in certain neurological disorders,” says Dr. Lozano. “By pinpointing and correcting the precise circuits in the brain associated with the symptoms of some of these conditions, we are finding additional options to treat these illnesses.”
While the treatment is still considered experimental, it is believed to work by stimulating a specific area of the brain to reverse abnormalities linked to mood, anxiety, emotional control, obsessions and compulsions all of which are common in anorexia. In some cases after surgery, patients are then able to complete previously unsuccessful treatments for the disease. The research may not only provide an additional therapy option for these patients in the future, but also furthers practitioners’ understanding of anorexia and the factors that cause it to be persistent.
“There is an urgent need for additional therapies to help those suffering from severe anorexia,” says Dr. Woodside. “Eating disorders have the highest death rate of any mental illness and more and more women are dying from anorexia. Any treatment that could potentially change the natural course of this illness is not just offering hope but saving the lives for those that suffer from the extreme form of this condition.”
A leading international expert in the field of DBS research, Dr. Lozano has been exploring the potential of DBS to treat a variety of conditions. Most recently, his team began the first ever DBS trial of patients with early Alzheimer’s disease, and showed that stimulation may help improve memory. This trial has now entered its second phase and expanded to medical centres in the United States.
A new study published in Social Cognitive and Affective Neuroscience by researchers at the Center for BrainHealth at UT Dallas and UT Southwestern found brain-based differences in how women with and without anorexia perceive themselves. The findings shed light on how brain pathways function in ill and fully recovered individuals who have had anorexia nervosa.
ScienceDaily (June 25, 2012) — Deep brain stimulation reduces binge eating in mice, suggesting that this surgery, which is approved for treatment of certain neurologic and psychiatric disorders, may also be an effective therapy for obesity. Presentation of the results took place June 25 at The Endocrine Society’s 94th Annual Meeting in Houston.
"Doing brain surgery for obesity treatment is a controversial idea," said the study’s presenting author, Casey Halpern, MD, a fifth-year neurosurgery resident physician at the University of Pennsylvania, Philadelphia. "However, binge eating is a common feature of obese patients that frequently is associated with suboptimal treatment outcomes."
Currently the U.S. Food and Drug Administration has approved deep brain stimulation for use in various conditions that affect the brain, including Parkinson’s disease and essential tremor. The procedure does not destroy any part of the brain and typically does not cause pain, Halpern said.
Available treatments of obesity may inadequately address the neural basis of this compulsive overeating behavior, he suggested. A region of the brain called the nucleus accumbens is known to be dysregulated in both rodents and people who binge eat. Therefore, Halpern and his co-workers targeted that brain region with deep brain stimulation in a strain of obesity-prone mice.
The surgery involved implanting an electrode in the nucleus accumbens. Wires connected the electrode to an external neurostimulator, a device similar to a pacemaker. When switched on, the stimulator triggers the electrode to deliver continuous electrical pulses to the brain.
After recovery from surgery, the mice received high-fat food at the same time every day for one hour, and the researchers measured their food consumption. Binge eating was defined as consuming 25 percent or more of the usual daily caloric intake during this period.
For one week, mice consistently binged, eating almost half of their daily calories during this one hour, the authors reported. Then on alternating days, the investigators turned on the stimulator. On the days that deep brain stimulation was administered, or “on,” the scientists observed a significant (approximately 60 percent) decrease in consumption of the high-fat diet. On the alternate days when they turned off the stimulator, binge eating returned, Halpern said.
The researchers then studied how deep brain stimulation might work to improve binge eating. With medications, they blocked various receptors of dopamine neurons, or nerve cells. Dopamine is a brain neurotransmitter, a chemical messenger, whose release in the brain is linked to the desire for rewarding behaviors such as eating high-fat food, according to Halpern.
Only one of the medications had an effect. Raclopride, which blocks the type 2 dopamine receptor, weakened the beneficial effect of deep brain stimulation by 50 percent.
Their results, Halpern said, showed that “at least one way that deep brain stimulation functions to suppress binge eating might be by modulating activity of neurons expressing the type 2 dopamine receptor.”
Source: Science Daily