In a dark, nondescript room tucked away in the depths of a London research centre, Lucy Gallop is demonstrating how we might treat eating disorders in future.
Improbably, she presses on a pedal under a desk, like a driver pulling away in first gear. Magnetic pulses pass through an electromagnetic coil which is held to a patient’s head. Clicking sounds fill the room and the patient’s neural activity is temporarily altered over the course of a few minutes.
A brain scan is visible to her right, the target area already visualised.
“The neuronavigation tells you whether or not you’re at the right place,” Gallop says of the process, known as repetitive transcranial magnetic stimulation (rTMS). “It’s replicable so you know when the participants come in the next time, you’re stimulating the same area.”
Gallop’s work carries deep personal significance: “My sister had anorexia so I was exposed to family therapy from a young age. And truthfully, it really exposed me to how treatment is very difficult – making a full recovery from anorexia is very difficult.”
New treatment innovations are urgently needed for eating disorders, which affect an estimated 1.25 million people in the UK. Hospital admissions have almost doubled in the last six years and patients are sent hundreds of miles away from home for treatment. Earlier this month, new figures showed that one in six consultant posts in eating disorder services are vacant. Patients with eating disorders are twice as likely to die prematurely than the general population.
Results from the project, led by the psychiatrist Prof Ulrike Schmidt at the Institute of Psychiatry, Psychology and Neuroscience at King’s College London, have been cautiously promising.
“Our brain imaging and behavioural studies suggest that the way in which rTMS might work is by reducing activity in a brain region – the amygdala, involved in anxiety and threat responses – and dampening patients’ emotional arousal, stress and anxiety,” says Schmidt.
She says rTMS seems to affect attention, allowing patients to look towards food rather than away from it. It also appears to influence their choices, shifting towards “high-calorie tasty foods rather than their typical anorexia very low-calorie choices”.
Ultimately, she says, that means patients become more relaxed around eating. One participant credited rTMS for helping to dim the “punishing thoughts and catastrophic guilt” she had endured in her 30 years with anorexia.
“Whilst the difference is small, it is hugely significant. It has allowed me to eat morsels of food that would have not only been immediately dismissed before the therapy, they would have made me want to scream,” the patient said.
It is relatively early days for rTMS (which has also been trialled in bulimia), which the researchers emphasise currently works best alongside traditional talking therapy. A 2018 randomised controlled trial showed 45% of those with anorexia receiving real rTMS reached normal weight 18 months after the study, compared with about 10% of those who received a sham treatment.
However, participant numbers were small and there was a placebo effect during treatment. “One needs to exert a degree of caution here,” Schmidt says, warning about the unrealistic promises some private rTMS clinics are making to patients and families. “Only proper large-scale trials will be able to answer the question of whether the early encouraging results of rTMS treatment in anorexia nervosa hold up to further scrutiny.”
The huge demand for treatment, and the paucity of existing services, appear to be stimulating an array of experimentation in the field. A second “neuro-hack” under development involves deep brain stimulation (DBS), an established surgical procedure in Parkinson’s. Seven people with longstanding and severe anorexia have been recruited to a pilot study at the University of Oxford – preliminary results are expected towards the end of 2020.
The aim, explains one of the investigators, the psychiatrist Rebecca Park, is to stimulate a brain region called the nucleus accumbens, the “hedonic hotspot” which is central to reward processing.
“In eating disorders, what is rewarding in life changes,” Parks explains. “It’s as if reward becomes warped towards pursuit of thinness. The eating and exercise rituals, obsessions and habits that characterise the disorder become entrenched over time.”
The DBS process, which can trigger complications, involves implanting electrodes into the brain that are linked by extension leads to an implanted pulse generator (in the form of a rechargeable pacemaker) placed beneath the skin below the collarbone.
The researchers quote “an overall risk of stroke of less than 1%, a haemorrhage-causing death of 0.01% and a risk of wound infection of 5%”. There are concerns about trialling a treatment that is so invasive and experimental without definitive data to support its use. The team’s ethical framework will include “checks and balances at all stages, supported by an independent ethicist who will act as a patient advocate”.
Park concedes “there is a risk of instilling false hope, as DBS is not a magic bullet and is unlikely to help everyone”. Nevertheless she believes that evaluating it ethically for anorexia is a step in the right direction.”
A third group of researchers based in Barcelona are innovating in a completely different space: a video game with built-in biofeedback that rewards emotional control.
On a virtual tropical island, gamers enjoy sun and sand before experiencing tumultuous storms. The app is connected through Bluetooth to a single sensor that transmits heart rate and heart rate variability data from participants to the device. If participants can regulate their reactions and remain calm, their cardiac response is registered by the sensor, which rewards them by dissipating the storm. If they cannot regulate their emotions, the storm intensifies.
This is biofeedback – gameplay dynamically adjusting to reactions. Improving this sort of emotional control can help those with eating and gambling disorders, conditions which both affect impulse control and emotional regulation, says Fernando Fernández-Aranda, head of the eating disorders unit at Bellvitge University hospital in Barcelona, who developed the game along with colleague Susana Jiménez-Murcia.
None of these innovations can mask a shortfall of funding and expertise, as evidenced by the deaths of Averil Hart, who endured “clear failures of care”, and Hannah Bharaj, who was denied anorexia treatment. A recent Commons report concluded a lack of understanding was costing lives. Making the most of emerging technologies also means training health professionals and funding resources.
Meanwhile, trials like the one at King’s College London will continue to search for treatments. Gallop, whose sister did eventually recover, aims to trial TMS in younger people, who she believes might respond especially well because of their brain plasticity.
“I think it gives parents hope,” she says, “especially if your child has already gone through an unsuccessful trial of talking therapy, you kind of feel like you’re running out of options.”
For these families, the hunt for a cure must continue.
This article is part of a series on possible solutions to some of the world’s most stubborn problems. What else should we cover? Email us at [email protected]
In the UK the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is on 13 11 14. Other international suicide helplines can be found at www.befrienders.org.
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