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

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.

Transcranial magnetic stimulation of medial prefrontal cortex modulates implicit attitudes towards food

“…These results have led researchers to consider the prefrontal cortex as part of a neural circuit contributing to the pathophysiology of eating disorders (Kaye, Wagner, Fudge, & Paulus, 2011) and therefore an interesting candidate as cortical target for studies aiming at exploring the modulatory effects of non-invasive brain stimulation techniques on food-related behaviour (McClelland, Bozhilova, Campbell, & Schmidt, 2013). Indeed, medial and dorsolateral prefrontal cortices have been selected as target sites in studies with transcranial direct current stimulation (tDCS) or transcranial magnetic stimulation (TMS) showing that stimulation sessions reduced food craving in healthy participants (Fregni et al, 2008;Goldman et al, 2011;Uher et al, 2005) and pathological feelings and behaviour in participants with eating disorders (Downar, Sankar, Giacobbe, Woodside, & Colton, 2012;Van den Eynde et al, 2010;Van den Eynde, Guillaume, Broadbent, Campbell, & Schmidt, 2013). However, the mechanisms underlying the behavioural outcome and how stimulation of specific target areas could modulate attitudes towards food are still poorly understood.…”

Microstructural effects of Ramadan fasting on the brain: a diffusion tensor imaging study

“…Neuroimaging studies about hypothalamus, insula, amygdala, middle temporal cortex, thalamus, and medial prefrontal cortex, which were the affected hunger and satiety centers in the current study, have highlighted the crucial role of these brain locations in the neurobiology of eating disorders and, particularly, in the related emotional regulation deficits (23)(24)(25)(26)(27)(28)(29)(30). Hypothalamus, thalamus, and amygdala, which are parts of limbic system, have major roles in processing emotions and memory (25).…”

“…Amygdala also plays a pivotal role in regulating anxiety and thus coping with self-injurious behavior (23). Dorsomedial prefrontal cortex has a central role in emotion regulation and the pathophysiology of major depression (26). The medial prefrontal cortex and temporal cortex are associated with socioemotional responses (24).…”

MRI-guided dmPFC-rTMS as a Treatment for Treatment-resistant Major Depressive Disorder

“…rTMS, and dmPFC-rTMS in particular, may also probe to be a promising option in other medication-resistant psychiatric illnesses including eating disorders 10 , obsessive-compulsive disorder 37 , and post-traumatic stress disorder 38 . Identifying good treatment candidates for these disorders may require additional tools other than traditional symptom-based diagnostic classification schemas -in particular, neuroimaging.…”

“…The conventional cortical target for MDD-rTMS is the dorsolateral prefrontal cortex (DLPFC) 8 . However, convergent evidence from neuroimaging, lesion, and stimulation studies identifies the dorsomedial prefrontal cortex (dmPFC) as a potentially important therapeutic target for MDD 9 and a variety of other psychiatric disorders characterized by deficits in self-regulation of thoughts, behaviors, and emotional states 10 . The dmPFC is a region of consistent activation in emotional regulation 11 , behavioral regulation 12,13 .…”