Unanticipated Rapid Remission of Refractory Bulimia Nervosa, during High-Dose Repetitive Transcranial Magnetic Stimulation of the Dorsomedial Prefrontal Cortex: A Case Report

Jonathan Downar, Ashwin Sankar, Peter Giacobbe, Blake Woodside, Patricia Colton, Jonathan Downar, Ashwin Sankar, Peter Giacobbe, Blake Woodside, Patricia Colton

Abstract

A woman with severe, refractory bulimia nervosa (BN) underwent treatment for comorbid depression using repetitive transcranial magnetic stimulation (rTMS) of the dorsomedial prefrontal cortex (DMPFC) using a novel technique. Unexpectedly, she showed a rapid, dramatic remission from BN. For 5 months pre-treatment, she had reported two 5-h binge-purge episodes per day. After rTMS session 2 the episodes stopped entirely for 1 week; after session 10 there were no further recurrences. Depression scores improved more gradually to remission at session 10. Full remission from depression and binge-eating/purging episodes was sustained more than 2 months after treatment completion. In neuroimaging studies, the DMPFC is important in impulse control, and is underactive in BN. DMPFC-rTMS may have enhanced the patient's ability to deploy previously acquired strategies to avoid binge-eating and purging via a reduction in her impulsivity. A larger sham-controlled trial of DMPFC-rTMS for binge-eating and purging behavior may be warranted.

Keywords: anorexia; bulimia; depression; dorsomedial; impulsivity; prefrontal; rTMS; transcranial.

Figures

Figure 1
Figure 1
Binge-purge episode incidence before, during, and after rTMS of the DMPFC. Full remission from binge-purge episodes was achieved by the third week of treatment, and was sustained for 9 weeks after the completion of treatment. Note that the treatment and post-treatment periods are separated purely for schematic reasons in this figure; in terms of temporal sequence, post-treatment week 1 immediately followed rTMS treatment week 4 with no intervening period.

References

    1. Bora E., Fornito A., Pantelis C., Yucel M. (2012). Gray matter abnormalities in major depressive disorder: a meta-analysis of voxel based morphometry studies. J. Affect. Disord. 138, 9–1810.1016/j.jad.2011.03.049
    1. Brass M., Haggard P. (2007). To do or not to do: the neural signature of self-control. J. Neurosci. 27, 9141–914510.1523/JNEUROSCI.0924-07.2007
    1. Brody A. L., Mandelkern M. A., Olmstead R. E., Jou J., Tiongson E., Allen V., Scheibal D., London E. D., Monterosso J. R., Tiffany S. T., Korb A., Gan J. J., Cohen M. S. (2007). Neural substrates of resisting craving during cigarette cue exposure. Biol. Psychiatry 62, 642–65110.1016/j.biopsych.2006.10.026
    1. Brownley K. A., Berkman N. D., Sedway J. A., Lohr K. N., Bulik C. M. (2007). Binge eating disorder treatment: a systematic review of randomized controlled trials. Int. J. Eat. Disord. 40, 337–34810.1002/eat.20370
    1. Campbell-Meiklejohn D. K., Woolrich M. W., Passingham R. E., Rogers R. D. (2008). Knowing when to stop: the brain mechanisms of chasing losses. Biol. Psychiatry 63, 293–30010.1016/j.biopsych.2007.05.014
    1. Daskalakis Z. J., Levinson A. J., Fitzgerald P. B. (2008). Repetitive transcranial magnetic stimulation for major depressive disorder: a review. Can. J. Psychiatry 53, 555–566
    1. De Ridder D., Vanneste S., Kovacs S., Sunaert S., Dom G. (2011). Transient alcohol craving suppression by rTMS of dorsal anterior cingulate: an fMRI and LORETA EEG study. Neurosci. Lett. 496, 5–1010.1016/j.neulet.2011.03.074
    1. Fichter M. M., Quadflieg N., Hedlund S. (2008). Long-term course of binge eating disorder and bulimia nervosa: relevance for nosology and diagnostic criteria. Int. J. Eat. Disord. 41, 577–58610.1002/eat.20539
    1. Guse B., Falkai P., Wobrock T. (2010). Cognitive effects of high-frequency repetitive transcranial magnetic stimulation: a systematic review. J. Neural Transm. 117, 105–12210.1007/s00702-009-0333-7
    1. Hadley D., Anderson B. S., Borckardt J. J., Arana A., Li X., Nahas Z., George M. S. (2011). Safety, tolerability, and effectiveness of high doses of adjunctive daily left prefrontal repetitive transcranial magnetic stimulation for treatment-resistant depression in a clinical setting. J. ECT 27, 18–2510.1097/YCT.0b013e3181ce1a8c
    1. Hausmann A., Mangweth B., Walpoth M., Hoertnagel C., Kramer-Reinstadler K., Rupp C. I., Hinterhuber H. (2004). Repetitive transcranial magnetic stimulation (rTMS) in the double-blind treatment of a depressed patient suffering from bulimia nervosa: a case report. Int. J. Neuropsychopharmacol. 7, 371–37310.1017/S1461145704004420
    1. Hayward G., Mehta M. A., Harmer C., Spinks T. J., Grasby P. M., Goodwin G. M. (2007). Exploring the physiological effects of double-cone coil TMS over the medial frontal cortex on the anterior cingulate cortex: an H2(15)O PET study. Eur. J. Neurosci. 25, 2224–223310.1111/j.1460-9568.2007.05430.x
    1. Hudson J. I., Hiripi E., Pope H. G., Jr., Kessler R. C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol. Psychiatry 61, 348–35810.1016/j.biopsych.2006.03.040
    1. Joos A. A., Saum B., Zeeck A., Perlov E., Glauche V., Hartmann A., Freyer T., Sandholz A., Unterbrink T., Elst L. T., Tuscher O. (2011). Frontocingular dysfunction in bulimia nervosa when confronted with disease-specific stimuli. Eur. Eat. Disord. Rev. [Epub ahead of print].10.1002/erv.1132
    1. Kober H., Mende-Siedlecki P., Kross E. F., Weber J., Mischel W., Hart C. L., Ochsner K. N. (2010). Prefrontal-striatal pathway underlies cognitive regulation of craving. Proc. Natl. Acad. Sci. U.S.A. 107, 14811–1481610.1073/pnas.1007779107
    1. Koenigs M., Grafman J. (2009). The functional neuroanatomy of depression: distinct roles for ventromedial and dorsolateral prefrontal cortex. Behav. Brain Res. 201, 239–24310.1016/j.bbr.2009.03.004
    1. Koenigs M., Huey E. D., Calamia M., Raymont V., Tranel D., Grafman J. (2008). Distinct regions of prefrontal cortex mediate resistance and vulnerability to depression. J. Neurosci. 28, 12341–1234810.1523/JNEUROSCI.2324-08.2008
    1. Kuhn S., Gallinat J., Brass M. (2011). “Keep calm and carry on”: structural correlates of expressive suppression of emotions. PLoS ONE 6, e16569.10.1371/journal.pone.0016569
    1. Lam R. W., Chan P., Wilkins-Ho M., Yatham L. N. (2008). Repetitive transcranial magnetic stimulation for treatment-resistant depression: a systematic review and metaanalysis. Can. J. Psychiatry 53, 621–631
    1. Mangweth B., Hudson J. I., Pope H. G., Hausmann A., De Col C., Laird N. M., Beibl W., Tsuang M. T. (2003). Family study of the aggregation of eating disorders and mood disorders. Psychol. Med. 33, 1319–132310.1017/S0033291703008250
    1. Mitchell J. E., Agras S., Wonderlich S. (2007). Treatment of bulimia nervosa: where are we and where are we going? Int. J. Eat. Disord. 40, 95–10110.1002/eat.20282
    1. Muhlau M., Gaser C., Ilg R., Conrad B., Leibl C., Cebulla M. H., Backmund H., Gerlinghoff M., Lommer P., Schnebel A., Wohlschlager A. M., Zimmer C., Nunnemann S. (2007). Gray matter decrease of the anterior cingulate cortex in anorexia nervosa. Am. J. Psychiatry 164, 1850–185710.1176/appi.ajp.2007.06111861
    1. Schafer A., Vaitl D., Schienle A. (2010). Regional grey matter volume abnormalities in bulimia nervosa and binge-eating disorder. Neuroimage 50, 639–64310.1016/j.neuroimage.2009.12.063
    1. Schonfeldt-Lecuona C., Cardenas-Morales L., Freudenmann R. W., Kammer T., Herwig U. (2010). Transcranial magnetic stimulation in depression – lessons from the multicentre trials. Restor. Neurol. Neurosci. 28, 569–576
    1. Schutter D. J., van Honk J. (2006). A standardized motor threshold estimation procedure for transcranial magnetic stimulation research. J. ECT 22, 176–17810.1097/01.yct.0000235924.60364.27
    1. Shapiro J. R., Berkman N. D., Brownley K. A., Sedway J. A., Lohr K. N., Bulik C. M. (2007). Bulimia nervosa treatment: a systematic review of randomized controlled trials. Int. J. Eat. Disord. 40, 321–33610.1002/eat.20318
    1. Sheline Y. I., Price J. L., Yan Z., Mintun M. A. (2010). Resting-state functional MRI in depression unmasks increased connectivity between networks via the dorsal nexus. Proc. Natl. Acad. Sci. U.S.A. 107, 11020–1102510.1073/pnas.1000446107
    1. Stefurak T., Mikulis D., Mayberg H., Lang A. E., Hevenor S., Pahapill P., Saint-Cyr J., Lozano A. (2003). Deep brain stimulation for Parkinson’s disease dissociates mood and motor circuits: a functional MRI case study. Mov. Disord. 18, 1508–151610.1002/mds.10593
    1. Talairach J., Tournoux P. (1988). Co-Planar Stereotaxic Atlas of the Human Brain: 3-D Proportional System: An Approach to Cerebral Imaging. New York: Thieme
    1. Van den Eynde F., Claudino A. M., Mogg A., Horrell L., Stahl D., Ribeiro W., Uher R., Campbell I., Schmidt U. (2010). Repetitive transcranial magnetic stimulation reduces cue-induced food craving in bulimic disorders. Biol. Psychiatry 67, 793–79510.1016/j.biopsych.2009.11.023
    1. Vocks S., Tuschen-Caffier B., Pietrowsky R., Rustenbach S. J., Kersting A., Herpertz S. (2010). Meta-analysis of the effectiveness of psychological and pharmacological treatments for binge eating disorder. Int. J. Eat. Disord. 43, 205–217
    1. Wager T. D., Davidson M. L., Hughes B. L., Lindquist M. A., Ochsner K. N. (2008). Prefrontal-subcortical pathways mediating successful emotion regulation. Neuron 59, 1037–105010.1016/j.neuron.2008.09.006
    1. Walpoth M., Hoertnagl C., Mangweth-Matzek B., Kemmler G., Hinterholzl J., Conca A., Hausmann A. (2008). Repetitive transcranial magnetic stimulation in bulimia nervosa: preliminary results of a single-centre, randomised, double-blind, sham-controlled trial in female outpatients. Psychother. Psychosom. 77, 57–6010.1159/000110061

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren