The potential role of stimulants in treating eating disorders.

BACKGROUND: Many individuals with eating disorders remain symptomatic after a course of psychotherapy and pharmacotherapy; therefore, the development of innovative treatments is essential. METHOD: To learn more about the current evidence for treating eating disorders with stimulants, we searched for original articles and reviews published up to April 29, 2021 in PubMed and MEDLINE using the following search terms: eating disorders, anorexia, bulimia, binge eating, stimulants, amphetamine, lisdexamfetamine, methylphenidate, and phentermine. RESULTS: We propose that stimulant medications represent a novel avenue for future research based on the following: (a) the relationship between eating disorders and attention deficit/hyperactivity disorder (ADHD); (b) a neurobiological rationale; and (c) the current (but limited) evidence for stimulants as treatments for some eating disorders. Despite the possible benefits of such medications, there are also risks to consider such as medication misuse, adverse cardiovascular events, and reduction of appetite and pathological weight loss. With those risks in mind, we propose several directions for future research including: (a) randomized controlled trials to study stimulant treatment in those with bulimia nervosa (with guidance on strategies to mitigate risk); (b) examining stimulant treatment in conjunction with psychotherapy; (c) investigating the impact of stimulants on "loss of control" eating in youth with ADHD; and (d) exploring relevant neurobiological mechanisms. We also propose specific directions for exploring mediators and moderators in future clinical trials. DISCUSSION: Although this line of investigation may be viewed as controversial by some in the field, we believe that the topic warrants careful consideration for future research.

Understanding the effects of reductionist biological views of eating disorder etiology on patient attitudes and behavior.

While eating disorders were historically considered to be a result of psychological or environmental causes, current evidence suggests that eating disorders are the product of complex gene-environment interactions wherein heritable vulnerabilities are activated by multiple exposures to environmental stimuli over the lifespan. Despite the fact that this integrated biopsychosocial etiological view of eating disorders is accepted among many professionals in the eating disorder field, evidence suggests that the general public and some clinicians are susceptible to dualist, or reductionist, views of psychopathology. Currently, little is known about (a) the prevalence of reductionist biological views of eating disorder etiology in those with eating disorders (this view attributes the cause of eating disorders to predominantly biological factors but does not acknowledge psychosocial factors as important contributors), (b) the effects of reductionist biological views on clinical outcomes, and (c) the most effective methods for modifying these views. In this article, we present the results of a preliminary investigation on the relationship between perceived causes of eating disorders and the attitudes and behaviors of those with eating disorders. We then go on to propose specific avenues for further research on uncovering the effects of reductionist biological views of eating disorder etiology.

The costs and benefits of intensive day treatment programs and outpatient treatments for eating disorders: An idea worth researching.

Outpatient care (e.g., individual, group, or self-help therapies) and day treatment programs (DTPs) are common and effective treatments for adults with eating disorders. Compared to outpatient care, DTPs have additional expenses and could have unintended iatrogenic effects (e.g., may create an overly protective environment that undermines self-efficacy). However, these potential downsides may be offset if DTPs are shown to have advantages over outpatient care. To explore this question, our team conducted a scoping review that aimed to synthesize the existing body of adult eating disorder literature (a) comparing outcomes for DTPs to outpatient care, and (b) examining the use of DTPs as a higher level of care in a stepped care model. Only four studies met the predefined search criteria. The limited results suggest that the treatments have similar effects and that outpatient care is more cost-effective. Furthermore, no studies explored the use of DTPs as a higher level of care in a stepped care model (despite international guidelines recommending this approach). Given the clear dearth of literature on this clinically relevant topic, we have provided specific avenues for further research.

A feasibility study evaluating lisdexamfetamine dimesylate for the treatment of adults with bulimia nervosa.

OBJECTIVE: This study examined the feasibility, safety, and potential efficacy of lisdexamfetamine (LDX) as a treatment for adults with bulimia nervosa (BN). METHOD: An open-label 8-week feasibility study was conducted in participants with BN. Enrollment rate, dropout rate, safety outcomes, and eating disorder symptom change were examined. RESULTS: Eighteen of 23 participants completed the study per protocol. There was no participant-initiated dropout due to adverse drug reactions and no severe and unexpected adverse drug reactions. An average increase in heart rate of 12.1 beats/min was observed. There was a mean weight reduction of 2.1 kg and one participant was withdrawn for clinically significant weight loss. In the intent-to-treat sample, there were reductions in objective binge episodes and compensatory behaviors from Baseline to Post/End-of-Treatment (mean difference = -29.83, 95% confidence interval: -43.38 to -16.27; and mean difference = -33.78, 95% confidence interval: -48.74 to -18.82, respectively). DISCUSSION: Results of this study indicate that a randomized controlled trial would be feasible with close monitoring of certain safety parameters (especially over a longer time period as long-term safety is unknown). However, the results should not be used as evidence for clinicians to prescribe LDX to individuals with BN before its efficacy and safety are properly tested. TRIAL REGISTRATION NUMBER: NCT03397446.

Le trouble de l'accès hyperphagique: Aperçu actualisé à l'intention des professionnels des soins primaires.

OBJECTIF: Fournir aux professionnels des soins primaires un aperçu actualisé du trouble de l'accès hyperphagique (TAH), qui comporte des recommandations pertinentes. QUALITÉ DES DONNÉES: Une recension a été effectuée dans PubMed, PsycInfo et Google Scholar, sans restrictions temporelles, à l'aide des expressions clés en anglais binge eating disorder, treatment, review, guidelines, psychotherapy, primary care et pharmacotherapy. Le niveau des données probantes pour toutes les recommandations varie de I à III. MESSAGE PRINCIPAL: Le trouble de l'accès hyperphagique est associé à une grande détresse et à une incapacité considérable chez le patient, ainsi qu'à des comorbidités médicales et psychiatriques; il a été ajouté dans la 5e édition du Manuel diagnostique et statistique des troubles mentaux, en 2013. Les médecins de soins primaires sont bien placés pour le dépistage, le diagnostic et l'amorce du traitement du TAH. Une approche par étapes du traitement commence par un développement personnel guidé, suivi par l'ajout ou le changement de la pharmacothérapie, ou par une psychothérapie individuelle, au besoin. Les psychothérapies dont l'efficacité est le plus corroborée par la recherche sont la thérapie cognitivo-comportementale, la thérapie interpersonnelle et la thérapie comportementale dialectique. CONCLUSION: Cet aperçu présente des conseils sur le dépistage, le diagnostic et les approches thérapeutiques fondés sur les données probantes actuellement disponibles, de même les avis d'un groupe diversifié d'experts, pour aider à orienter les cliniciens lorsque les données probantes sont limitées.

Examining the association between deficits in self-concept clarity and eating disorder severity.

OBJECTIVE: We sought to (1) compare self-concept clarity (SCC; the degree to which a person possesses a confidently defined, internally consistent, and stable sense of self) between female participants with and without eating disorders, (2) examine associations between SCC deficits and severity of eating disorder specific and related psychopathology in individuals with eating disorders, and (3) determine if there is a unique association between SCC deficits and eating disorder severity, controlling for related psychopathology. METHOD: Participants (M age = 23.16 years) with eating disorders (n = 121) and controls (n = 63) completed semi-structured clinical interviews and self-report assessments. RESULTS: SCC deficits were significantly greater in the eating disorder compared to the control group. In the eating disorder group, greater SCC deficits were significantly associated with greater severity of eating pathology, depression, impulsivity, and trait anxiety. In a hierarchical regression analysis, significant associations between SCC deficits and Eating Disorder Examination (EDE) Global scores were better accounted for by shared variance with anxiety. DISCUSSION: SCC deficits may reflect a transdiagnostic feature related to the severity of a range of mental health problems, suggesting potential benefit of transdiagnostic interventions.

Secondary outcomes and qualitative findings of an open-label feasibility trial of lisdexamfetamine dimesylate for adults with bulimia nervosa.

BACKGROUND: There is emerging evidence that stimulants warrant further investigation as a treatment for bulimia nervosa (BN) including a recent open-label feasibility trial examining the use of lisdexamfetamine dimestylate (LDX) for BN. The current report presents the secondary outcomes and qualitative interview results from that feasibility trial. These outcomes explore several purported mechanisms that may explain how stimulants affect symptoms of BN: appetite, impulsivity, obsessive and compulsive symptoms, eating disorder psychopathology/impairment and reward-based decision-making. METHODS: Twenty-three participants with BN received LDX for eight weeks. Questionnaires assessing appetite, impulsivity, obsessive and compulsive symptoms, eating disorder psychopathology and impairment were administered at baseline and post-treatment. Participants also completed a two-step reinforcement learning task to assess their decision-making. Semi-structured interviews took place at baseline, week 5, and follow-up. RESULTS: Reductions in hunger, food-related impulsivity, obsessive and compulsive features, eating disorder psychopathology and impairment were found. However, reward learning, as far as it is assessed by the task, did not seem to contribute to the effect of LDX on BN symptoms. Qualitative analysis suggested four themes: (1) reprieve from the eating disorder, (2) improvement in function and quality of life, (3) renewed hope for recovery, and (4) ability to normalize eating. CONCLUSIONS: This report suggests several potential mechanisms by which LDX may reduce symptoms of binging and purging in those with BN. Importantly, due to the open-label design, we are unable to attribute findings to the medication. Instead, our results should be interpreted as hypothesis generating to inform future studies such as adequately powered randomized controlled trials. Trial registration NCT03397446.

Recent research suggests that stimulant medications could be a potential treatment for bulimia nervosa (BN). Participants in this study took lisdexamfetamine dimesylate (LDX) for 8 weeks while their eating disorder symptoms and medical status were carefully monitored. As part of this study, twenty-three participants with BN completed several interviews, questionnaires and computer tasks at the start and end of treatment which were delivered to help researchers learn more about the how LDX impacts people with BN. Scores on questionnaires measuring different aspects of the eating disorder improved over time. Participants' performance on the computer task which measures a type of decision making did not change during treatment. Interviews exploring participants' experience taking LDX found four common themes: reprieve from the eating disorder, improvement in function and quality of life, renewed hope for recovery, and ability to normalize eating. This report suggests several potential ways LDX may reduce symptoms of binging and purging in those with BN. Importantly, due to the size and type of study, we cannot conclude that changes observed were a direct result of the medication. Instead, our results should be used to form new questions that can be explored by larger studies with controlled designs.