D. Blake Woodside, MD

[[{"type":"media","view_mode":"media_crop","fid":"23135","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_7260563962522","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"1772","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"margin: 5px; float: right;","title":" ","typeof":"foaf:Image"}}]]Anorexia nervosa (AN) is a serious medical condition with a high rate of both mortality and chronicity. Affecting both men and women, the mortality rate for the condition is estimated at 10% to 15%, and an additional 10% to 15% will go on to develop a chronic form of the illness.

Current treatments are able to help many individuals who suffer from this disorder. While there have been promising advances over the last decade in the treatment of adolescent AN through the development of novel forms of family therapy, there have been few significant improvements in treatment for adults, especially those with chronic illness. Treatments focused on this group would have a significant effect on reducing both mortality and general suffering experienced by these individuals.

Deep Brain Stimulation (DBS) is a neurosurgical procedure initially developed for the management of treatment-refractory movement disorders, such as Parkinson disease and essential tremor. More recently, there has been interest in investigating the use of the procedure in other circuit-based disorders, including psychiatric conditions, such as depression, OCD, schizophrenia, and Alzheimer dementia. Since 1987, over 100,000 individuals have had the procedure for neurological or psychiatric conditions, and the number of trials for new indications continues to grow.

During a DBS procedure, electrodes are introduced bilaterally under stereotactic and fluoroscopic guidance to deep brain targets identified on a pre-operative MRI. These electrodes are tested in the operating room with the patient awake and under local anesthesia, and then in a separate procedure the electrodes are connected to a programmable stimulator implanted in the anterior chest wall. The device is then activated a short period of time later, with the parameters of the stimulation monitored externally. The battery life for the stimulator depends on the intensity of the stimulation, but is typically 2 to 4 years. Replacements are performed with local anesthesia and sedation.

The rationale for the use of DBS in AN derives from several sources.

 The insula has been implicated in interoception-that is, in the way in which the body is experienced internally, and appears to be involved in decisions about acceptability of food. The anterior cingulated (AC), and in particular the subcallosal cingulate (SCC), appear to be implicated both structurally and functionally in the symptoms of AN. The AC is also involved in both mood states and the regulation of affect, both directly and through its influence on higher cortical structures. Finally, the ventral striatum, or nucleus accumbens (NAC), may be involved in reward circuits, with some research suggesting that the NAC does not function normally in anorexia nervosa patients compared with healthy controls. It was thus thought that stimulation of either the AC or NAC would be potential targets for a trial of DBS in AN.

In our research, we decided to focus our attention on the AC, and specifically the subcallosal cingulate. The rationale for this decision related to our understanding that alterations in mood and the regulation of mood seem to have a very important role in the initiation and maintenance of AN. We also were able to assess the response to AC stimulation in depression, given the presence of a large series of cases in our setting. Our initial work has been a phase I clinical trial to establish safety and tolerability: we are presently in the midst of a phase II trial to start the process of evaluating efficacy. Entry criteria for the trial includes a history of either chronic, treatment- resistant AN, or malignant AN. Risk of a premature death in the reasonably near future was an important factor to consider in selecting subjects suitable for the trial, which does represent a last hope for many subjects.

Our study presently has 15 subjects enrolled who have had the procedure. Six further patients are awaiting surgery. We recruited our first 12 patients in approximately 14 months. By comparison, in the first trial of DBS for depression conducted in this setting, it took two years to recruit the first 6 subjects. This alone suggests that there is a meaningful population of individuals with chronic, severe AN who are willing to undergo experimental neurosurgery in the hope that they might derive some benefit from the procedure.

We set a threshold of a BMI of 13 to be able to perform the surgery. Several subjects required hospitalizations before surgery to make them suitable for the procedure.

Our operative experience has been positive, with few adverse events, none of which were unexpected. Patients tolerated the procedure well, and there were few post-operative complications. One patient, with severe comorbid OCD did find it impossible to resist picking at the incision line in her scalp and we eventually had to remove the device.

We initially reported on 6 patients and we now have 8 subjects, on whom we have 1- to 2-year follow-up data.

 Other subjects have shorter periods of follow-up available, and we will report on these separately. We presented data on our first 8 patients in the fall of 2013.

 From a psychometric perspective, there are significant improvements in mood, anxiety, and obsessionality by 6 months post-simulator activation. These improvements occur outside of any active treatment for the most part and are striking given the notable difficulty in generating such improvements in very underweight individuals. Weight showed an initial decline back to pre-surgery levels, but was slowly increasing by 6 months.

There were some improvements in other core eating disorder (ED) symptoms, including reduced levels of bingeing and purging, and exercise. We noted consistent improvements in comorbid OCD and PTSD in several subjects who suffered from these conditions. Anecdotally, patients reported much better affective regulation, and explained symptom reduction, when it occurred, as a function of having much better control over their responses to affective events.

Of these 8 subjects, 6 decided to re-enter specialized treatment for their AN in the 4- to 9-month period post-surgery. None of these patients had previously been able to become fully weight restored, and between them they had over 50 intensive treatments. Strikingly, all 6 were able to complete treatment, and with much less difficulty than expected. Improved mood, decreased anxiety, and better regulation of affect seemed to allow these patients to tolerate the treatment more easily-and most reported having been able to do therapeutic work in treatment that they had not previously felt comfortable with.

Brain imaging, via positron emission tomography (PET), has shown significant changes in cerebral glucose metabolism in key AN-relevant brain structures, including the subcallosal cingulate, insula, and parietal lobe. These results are consistent with our initial hypotheses relating to brain circuit functioning in AN.

We have had 3 long-term good outcomes from this cohort, two of whom are weight restored at 10 to 12 months, after 17, 20, and 35 years’ duration of illness. Several of these subjects have required a battery replacement. Interestingly, several subjects who have not had any meaningful response in terms of their ED have also decided to have their battery replaced, as well.

These findings are extremely preliminary and need to be considered with some care. The possibility of a placebo response cannot be ruled out, and this will require a sham-controlled trial. The apparent responses in terms of mood, anxiety, affective regulation, and ED symptom change, while appearing to be fairly robust in the face of significant dietary restraint, can attenuate if the patient’s nutritional state deteriorates sufficiently-and then return with even a small improvement in eating.

The availability of functional brain imaging as a routine part of therapeutic trials in psychiatry-via PET and functional magnetic resonance imaging-do open up an exciting new door to our understanding, not only of brain functioning in AN, but also to the direct effect of our treatments of brain function.

Finally, the long-term acceptability of surgical treatments for psychiatric illness such as AN remains an open question. With the advent of new surgical techniques that improve the side-effect profile of the procedures, it is certainly possible that we may see a continuing interest in techniques such as DBT.

Dr  Woodside is Medical Director, Program for Eating Disorders, Toronto General Hospital, and Professor, Department of  Psychiatry, University of Toronto, Toronto, Ontario, Canada. Dr Lipsman is a  resident in the Department of Neurosurgery, Toronto Western Hospital, Toronto,  Ontario, Canada. Dr Lozano is Chair, Division of Neurosurgery, Toronto Western  Hospital, and Professor, Department of Surgery, University of Toronto, Toronto,  Ontario, Canada.

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Articles

Deep Brain Stimulation is a neurosurgical procedure initially developed for the management of treatment-refractory movement disorders. More recently, the rationale for the use of DBS in anorexia nervosa derives from several sources.

Deep Brain Stimulation in Chronic and Severe Anorexia Nervosa

The high rate of comorbid substance abuse in women with bulimia nervosa (BN) has remained consistent in the literature. This article reviews the prevalence of substance abuse in BN and summarizes treatment approaches for persons with BN and comorbid substance abuse.

Studies conducted in community and clinical settings continue to demonstrate that the prevalence of substance use disorders is higher among women with BN than in women with other eating disorder diagnoses and in women in the general population.

 reported on the prevalence of alcohol use disorders and BN in a national sample of 3006 women; approximately 31% of the women with BN had a history of alcohol abuse. In comparison, 21.7% of women who did not have an eating disorder reported this history.

 examined the point prevalence of psychiatric comorbidity in 2436 female inpatients who had been admitted to an eating disorder program with varying primary eating disorder diagnoses. Significant differences between eating disorder diagnostic groups and comorbid substance use disorders were found during assessments performed at admission and discharge. In particular, inpatients with BN were twice as likely to have alcohol abuse/dependence (26%) than those with anorexia nervosa restricting subtype (3%), anorexia nervosa binge-purge subtype (14%), and eating disorder not otherwise specified (14%). Moreover, inpatients who had BN were 3 times more likely to have polysubstance abuse/dependence than women with anorexia nervosa restricting type (10% vs 2%, respectively).

These results are similar to those of an earlier study conducted in a clinical setting, in which 24% of women with BN and 17% of women with anorexia nervosa were found to have a 

 summarizes studies that have examined comorbid substance use/abuse/dependence and eating disorders.

Women with BN abuse an unusually wide range of substances. Substances commonly abused by this population include alcohol, street drugs (eg, cocaine and marijuana), prescribed medications, and non-psychoactive substances (eg, laxatives, emetics, diuretics, and diet pills). Young women with BN are at greatest risk for abusing substances and experimenting with many types of substances.

The literature concerning alcohol use disorders and BN has been quite consistent. Findings suggest that alcohol use disorders tend to co-occur more often in women with bulimic symptoms (eg, women with BN or anorexia nervosa binge-purge subtype) than in women with restricting symptoms (eg, those with anorexia nervosa restricting subtype).

Similarly, rates of illicit drug use have generally been found to be higher in women with BN than in women with anorexia nervosa. Wiederman and Pryor

 found that more women with BN reported having used amphetamines (18%), barbiturates (10%), marijuana (24.7%), and cocaine (12.5%) than women with anorexia nervosa (3%, 2.2%, 5.2%, and 1.5%, respectively).

Women with BN may become physically and/or psychologically dependent on prescription medications, such as tranquilizers, benzodiazepines, and hypnotics, at therapeutic doses. Women with BN self-medicate and increase their doses of psychotropic drugs significantly more than women with anorexia nervosa restricting subtype.

Moreover, the use of non-psychoactive substances, which initially may be used in an attempt to control or modify body weight or shape, later develops into an addictive pattern in most women with eating disorders.

The literature suggests that the association between BN and substance use disorder may be more specific. That is, substance use disorders may be associated with bulimic symptoms, such as bingeing or purging, rather than simply BN.

Causality of comorbid bulimia nervosa and substance abuse

Why do women with BN have such high rates of substance use and misuse? One possible explanation is that such women may have underlying impulsive personality traits. Such traits may be unique to a subset of so-called multi-impulsive bulimics. These women engage in other impulsive behaviors, such as gambling, shoplifting, promiscuity, and substance use, in addition to their impulsive eating disorder behaviors.

 The origin of such impulsivity is not known.

However, the observation of high rates of physical and sexual abuse in patients with BN may offer some clues.

 Higher rates of substance abuse are known to occur in individuals with posttraumatic stress disorder. Similarly, bulimic behaviors, such as bingeing and purging and alcohol and drug use, may be a means of regulating emotional disturbances. These emotional disturbances could be related to a history of childhood trauma.

Moreover, comorbid Axis I and II disorders, such as depression and borderline personality disorders, are frequently diagnosed in women with BN or substance use disorders. These additional diagnoses may moderate the association between BN and substance abuse. Again, the connection between the development of Axis II disorders and a history of trauma is not well understood and deserves further attention.

Finally, some research shows elevated rates of substance abuse in the families of individuals who have BN.

 The development of one or the other condition may act as a trigger that precipitates the onset of the second illness, despite each of them being inherited separately.

Women with BN endure a wide range of severe and debilitating symptoms. The addition of a comorbid substance use disorder not only exacerbates medical and psychiatric complications but also hinders clinical assessment and treatment. Often, women only seek treatment for either BN or a substance use disorder. However, expertise at treatment centers tends to fall into either the addiction or eating disorder fields, but rarely both. Consequently, many treatment centers may lack the expertise to treat both disorders concurrently. The adequate assessment of these comorbid disorders, especially in younger women, who are at greater risk for both disorders, is key to planning appropriate psychoeducation and treatment strategies.

The literature examining the influence of a history of substance use disorders on treatment outcomes in women with BN is scarce, and the findings from the few studies that do exist are mixed.

 conducted a clinical trial using desipramine to treat 75 women with BN. The women with a history of substance abuse responded better to the treatment and displayed fewer eating disorder symptoms than those who did not report a history of substance abuse. More recently, a history of substance abuse was found to predict a poorer response in a sample of 120 women with BN who were treated with psychotherapy and/or medication.

This divergence in findings in treatment outcome studies, along with the lack of research comparing treatment outcomes in women with BN with and without substance use problems, reveals the need for more research in this area. Sequential, simultaneous, and integrated strategies for women with BN and comorbid substance use disorders all exist.

involve treating each disorder separately in a stepwise approach. Such treatment often improves the symptoms of the disorder being treated and, in the process, worsens the symptoms of the second disorder. For example, if BN is first treated in a woman with comorbid alcohol abuse, her eating disorder symptoms may improve; because the alcohol problem has not been addressed, however, she may consume more alcohol to self-medicate.

address both the eating disorder and the substance use disorder at the same time. Although the 2 disorders are treated contemporaneously, treatment occurs in 2 separate tracks. Consequently, the patient may not be taught to link the 2 disorders and thus understand how they influence one another.

to be most effective for persons with comorbid eating and substance use disorders. This approach incorporates a single treatment that addresses both the eating disorder and the substance use disorder. Unfortunately, there is a lack of treatment outcome studies on integrated treatment and there are few integrated treatment programs.

Practitioners in outpatient practice may not have training or expertise to treat comorbid substance abuse. In these situations, clinicians should attempt to arrange for the patient to have access to specialized substance use services. In some cases, patients may need residential treatment for their substance use before being able to use outpatient services for the eating disorder effectively.

-both group and individual-is beneficial for women with BN and women with substance use disorders. Cognitive-behavioral therapy (CBT), in particular, has been found to be highly effective in persons with BN and those with substance use disorders.

 It might therefore be useful to incorporate CBT into treatments for women with comorbid BN and substance abuse.

Empirical data are lacking concerning the effects of specific pharmacological treatments for women with BN and comorbid substance use disorders. However, opioid antagonists have been found to decrease both binge eating and cravings for substances of abuse.

 Research suggests that SSRIs may be helpful for patients with comorbid substance use disorders and eating disorders.

Women with BN frequently have comorbid substance use disorders. The range and occurrence of substance use problems in these women far exceed those in women with other eating disorder diagnoses and in the general population. The association between BN and substance abuse could be explained by their inherent similarities. For example, both have been described as impulsive and addictive disorders frequently associated with other comorbid Axis I and II disorders. There is a lack of research examining treatment outcomes in women with comorbid eating disorders and substance use disorders and few integrated treatment programs exist for this population.


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Substance Abuse in Women With Bulimia Nervosa

The occurrence of eating disorders in men remains relatively rare but consistent. This is true despite recent research suggesting that male cases are far more numerous than had been previously thought. This brief article will comment on recent research findings in this area and describe their relevance to assessment and treatment.

Two studies support the notion that eating disorders are more common than had previously been thought (Health Canada, 2003; Woodside et al., 2001). Woodside et al. (2001) reported on the results of a 10,000-person community epidemiologic study. Combining full- and partial-syndrome eating disorder cases for both men and women, the investigators showed an overall rate of three female cases for every one male case-a far cry from the typical 10:1 or 20:1 ratio found in most treatment settings. However, this study assessed only limited Axis II parameters and, as 

 diagnoses were generated from the data, the prevalence of binge-eating disorder could not be assessed.

More recently, Health Canada (2003) released preliminary results from a national, face-to-face mental health survey of over 30,000 people performed in 2001 and 2002. This survey assessed for full-syndrome eating disorders and reported a ratio of male to female cases of approximately 1:5. This was somewhat higher than the findings from Woodside et al. (2001) but showed many more cases than might otherwise have been thought. The somewhat higher ratio in the Health Canada survey is almost certainly related to only full-syndrome cases that the Woodside et al. survey was too small to allow for.

Studies continue to show that the nature of the illness, when it occurs in men, is essentially indistinguishable from women. In Woodside et al. (2001), the sample of male eating disorder cases in the community was compared to female eating disorder cases in the same sample and a sample of 3,769 unaffected males. There were no significant differences in any variables relating to illness severity. As mentioned, both full- and partial-syndrome cases were included. Previous research showed that partial-syndrome cases did not differ from full-syndrome cases on most eating disorder variables; there was an excess of partial-syndrome cases of bulimia nervosa in males compared to females. This may have been an artifact of the small sample size in the study. 

Other studies have examined differences in personality between men and women with eating disorders (Fassino et al., 2001; Woodside et al., submitted for publication). These studies demonstrated that men with eating disorders had lower scores on the Temperament and Character Inventory (TCI) for Harm Avoidance, Reward Dependence and Cooperativeness. Our study also showed lower perfectionism in male cases. 

There is an extreme scarcity of literature regarding differential response to treatment in men with eating disorders compared to women. The literature that does exist suggests that men and women receive similar benefit from treatment for their eating disorder (Woodside and Kaplan, 1994). This is an area that deserves much more attention. 

We are thus left with a confusing situation: Men appear to suffer from eating disorders with a higher frequency than would be thought, based on data obtained from clinical settings, despite having a similar illness and similar responses to treatment. What could explain these findings and what impact might such explanations have for practicing clinicians? 

Why are fewer affected men identified in formal treatment settings? One possible explanation is that men simply do not see themselves as being at risk, and therefore dismiss or ignore symptoms that might be indicative of an illness requiring treatment. For example, a young woman who is overeating and vomiting would be quite likely to self-identify as having bulimia nervosa, due to the large amount of public attention that has been paid to these conditions. A young man with similar symptoms might simply think that his eating habits are bad or that he drinks too much, not paying too much attention otherwise. Friends-both male and female-might also have a lower index of suspicion for a formal eating disorder and attribute symptoms to other causes.

A young man who is losing weight might be identified as having a drug problem or AIDS, rather than suffering from anorexia nervosa. Again, neither male nor female friends might make the connection between the outward symptom and the presence of an illness, simply because of the societal expectation that individuals with eating disorders are all female.

The relevant message for clinicians is to be aware that men are at risk for eating disorders and to include a history of eating-related behaviors in their exams. This is particularly important in the identification of bulimia nervosa, which may have no outward symptoms.

Men may also be worried about assumptions about sexual orientation. There is a long controversy about the extent to which homosexual men might be over-represented among those males with eating disorders. To date, all the research done on this question has been in clinical samples and may be biased. Studies from these clinical populations have cited high rates of homosexual orientation (Herzog et al., 1984). Unfortunately, information on sexual orientation was not available for the Woodward et al. (2001) study. We are attempting to discover whether this information is available for the Health Canada (2003) study. Thus, there is no definitive answer to the question of sexual orientation and eating disorders.

One idea that has been raised to explain these findings is that homosexual men may be less reluctant to self-identify as suffering from an eating disorder because of the different focus on weight and shape in the homosexual male community. They may also simply be more willing to access treatment once they have identified their behaviors as troublesome. For the clinician, the most important issue to remember is to reassure heterosexual male patients that the diagnosis of an eating disorder does not require any specific sexual orientation and that no assumptions will be made about sexual orientation, one way or the other.

Men may be unwilling to enter treatment programs that are mainly for women. There is a fairly good awareness among both men and women about the extent to which eating disorders are a problem for women, which includes the idea that all available treatment programs are for women only. Alternately, men may experience a general reduction in help-seeking behaviors that is independent of diagnosis. I am unaware of any treatment programs specifically for men, aside from an occasional support group. Unfortunately, the lack of male-specific treatment programs reinforces the idea that treatment is only for women.

I am equally unaware of significant programs that exclude men. The reduced focus on treatment of men is usually related to the small number of men presenting for treatment--so a circular arrangement occurs. While there is little formal research on treatment outcome for men, most senior clinicians will indicate that the outcome appears to be similar for both men and women. I tell prospective male patients that the usual role a male patient ends up taking in a treatment group is that of a brother--someone the female patients trust and feel close to, but with whom there are clear boundaries. In my treatment programs, men are included in all aspects of the program when admitted. In fact, our female patients have told us that they appreciated having a male peer's input on issues pertaining to relationships, appearance and so forth.

For the clinician, the most important messages for male patients are that the treatment is the same for men and women and that men are generally welcomed, both by the treatment team and by other members of the treatment group. It is worth reassuring a male patient that he is likely to be accepted by the group and will find a comfortable place there.

Are there any differences in the treatment a male patient should receive? Generally, the answer to this question is no. Men respond to the same types of interventions as do women, to the best of our knowledge. There is sometimes a perception that men who are affected have more severe illness. This is probably due to the fact that when large numbers of male patients are compared to female patients, there are no significant differences.

Clinicians will of course be aware that men and women are socialized differently in Western culture, and while the overall process of eating disorder cognitions is the same, the precise content may be slightly different. For example, men are more involved in competitive sports and thus will talk more about their concerns about athletic prowess. 

It is important to remember that while rates of sexual abuse are lower in men than in women, that about 10% of men with an eating disorder reported a history of sexual abuse (Woodside et al., 2001). As is the case with women, such an occurrence may be an important factor in the etiology of the eating disorder.

The occurrence of eating disorders in men appears to be more common in the community than had previously been thought. There are a number of factors that may keep men out of treatment, ranging from lack of self-identification to perceived stigma. Once in treatment, men appear to respond in much the same way as do women.

 Fassino S, Abbate-Daga G, Leombruni P et al. (2001), Temperament and character in Italian men with anorexia nervosa: a controlled study with the temperament and character inventory. J Nerv Ment Dis 189(11):788-794.
 

 Health Canada (2003), Canadian Community Health Survey. Ottawa, Ontario: Statistics Canada.
 

 Herzog DB, Norman DK, Gordon C, Pepose M (1984), Sexual conflict and eating disorders in 27 males. Am J Psychiatry 141(8):989-990.
 

 Woodside DB, Bulik CM, Thornton L et al. (submitted for publication), Personality in men with eating disorders. J Psychosom Res.
 

 Woodside DB, Garfinkel PE, Lin E et al. (2001), Comparisons of men with full or partial eating disorders, men without eating disorders, and women with eating disorders in the community. Am J Psychiatry 158(4):570-574. 
 

 Woodside DB, Kaplan AS (1994), Day hospital treatment in males with eating disorders-response and comparison to females. J Psychosom Res 38(5):471-475.

Recent research has shown a higher incidence of men with eating disorders than previously thought. How do men with eating disorders differ from women in terms of assessment and treatment? What are the differences in risk factors and possible comorbidities, if any?

Author | D. Blake Woodside, MD

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