New studies review the effectiveness of brain stimulation techniques such as transcranial magnetic stimulation (TMS) for the clinical treatment of eating disorders.
Innovative Treatment for Eating Disorders: Transcranial Magnetic Stimulation (TMS)
Most people have heard of eating disorders, and understand they’re more than problems with eating too little or too much food. They know an eating disorder can lead to extreme behaviors like intentionally not eating – starving oneself – or things like purging – forcing oneself to vomit. They also understand the emotions related to eating disorders are intense, uncomfortable, and can be extremely disruptive.
- Eating disorders have the highest mortality rate of all mental health disorders – only opioid use disorder (OUD) has a higher mortality rate
- Studies show the mortality rate for people diagnosed with anorexia is 10%
- Eating disorders increase risk of suicide by an average of 5%
- Close to 50% of people with an eating disorder also reported disordered use of alcohol or substances
Statistically speaking, an eating disorder can be more disruptive and dangerous to the person who receives a diagnosis than major depressive disorder, bipolar disorder, schizophrenia, borderline personality disorder, or psychotic disorders. Eating disorders affect all areas of a person’s life: their bodies, thoughts, emotions, and behavior. An eating disorder can prevent an individual from participating in the basis activities of daily life, and have a negative impact on work, school, family life, and personal relationships.
Eating disorders are serious mental health conditions. That’s why we all need to learn more about them, and understand that the earlier a person with an eating disorder receives a diagnosis and enters treatment, the better the outcome.
What Are Eating Disorders?
The American Psychological Association (APA) offers this general definition of eating disorders:
“An eating disorder is any disorder characterized primarily by a pathological disturbance of attitudes and behaviors related to food.”
The National Eating Disorders Association (NEDA) elaborates on this definition:
“Eating disorders are serious but treatable mental and physical illnesses that can affect people of all genders, ages, races, religions, ethnicities, sexual orientations, body shapes, and weights.”
Mental health experts identify five types of eating disorders in the Diagnostic and Statistical Manual of Mental Disorders, Volume Five (DSM-5):
- Anorexia nervosa (AN)
- Bulimia nervosa (BN)
- Binge Eating Disorder (BED)
- Avoidant/restrictive eating disorder (ARFID)
- Other specified feeding and eating disorder (OSFED)
The trajectory of an eating disorder is unique to each person. An individual develops their eating habits – and an eating disorder, if they develop one – based on a combination of genetics, individual physiology, and personal history. Every person with an eating disorder displays symptoms in their own way. Symptoms appear in different degrees, intensities, and combinations. However, there are specific emotional, behavioral, and physical characteristics which, if present, may indicate the presence of an eating disorder.
Eating Disorders: Common Symptoms and Warning Signs
We’ll list the primary emotional, behavioral, and physical symptoms of eating disorders below, beginning the emotional and behavioral symptoms. The presence of these symptoms function as warning signs for the presence of an eating disorder.
Eating Disorders: Emotional and/or Behavioral Symptoms
- Preoccupation with weight loss, dieting, and control of food
- Preoccupation with appearance of body, especially size and shape
- Excessive fear of being considered overweigh/perceived as fat
- Elaborate rituals around food and eating: excess chewing, not allowing foods to touch one another on the plate, only eating one type of food/food group
- Daily counting of calories, carbohydrates, and/or grams of fat
- Extreme need or desire to look and/or feel thin
- Avoiding particular foods
- Refusing to eat food from a specific group, such as carbohydrates
- Extreme mood swings
- Withdrawal from friends, peers, and family
- Withdrawal from favorite activities
- Extreme discomfort eating around others
- Skipping meals/refusing to eat meals
- Sleep problems: too little or too much
- Irritability/anger
Eating Disorders: Physical Symptoms
- Eating more than usual in a short time, called binge-eating or binging
- Self-induced vomiting, called purging
- Noticeable changes in weight: gain or less
- Extreme thinness
- Muscle weakness
- Dizziness
- Constant nausea or stomach/gut issues
- Fainting
- Feeling cold all the time
- Irregular or abnormal menstruation
- Dry skin and hair
- Fine hair on body
- Brittle fingernails
- Yellowish skin
- Oral health problems: cavities, sensitive teeth, discolored teeth, decay cause by purging
- Impaired immune function resulting in frequent illness/poor wound healing
- Evidence of purging on hands: calluses or cuts on back of hand/fingers
Experts identify those symptoms as common to all eating disorders. Each disorder has a specific suite of associated symptoms, however, which lead to the five different diagnostic categories we list in the third section of this article. We’ll list the specific symptoms associated with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) below, then explain what differentiates avoidant/restrictive eating disorder (ARFID) and other specified feeding and eating disorder (OSFED) from AN, BN, and BED.
Anorexia Nervosa: Specific Symptoms
- Extreme weight loss
- Difficulty keeping a body weight considered medically healthy or appropriate for age, height, and build
- Extreme preoccupation with weight, food, counting calories, and dieting
- Often talks about feeling/looking fat
- May keep rigid and extreme exercise or workout routine
- Often dresses in layers to stay warm or hide weight loss
Bulimia Nervosa: Specific Symptoms
- Evidence of binge eating, including:
- Large amounts of food disappearing in a short time from fridge/pantry
- Presence of empty containers/wrapping/wrappers that indicates consumption of large amounts of food
- Evidence of purging, including:
- Going to the bathroom immediately after meals
- Sounds/smells of vomiting from bathroom
- Presence of packaging for laxatives or diuretics
- Excessive water drinking, use of mouthwash, mints, or gum to cover evidence or purging
- Calluses on hands/fingers from purging
- Dental problems – discoloration, decay, erosion – due to purging
Binge Eating Disorder: Specific Symptoms
- Frequent, recurring, and secret instances of binge eating
- Feeling unable to stop binge episodes or control/stop eating
- Self-directed feelings of disgust, depression, or guilt after binge eating
- Low self-esteem after binge eating
- Stealing food
- Hoarding food
- Organizes schedule around binge eating
- Evidence of binge eating:
- Large amounts of food disappearing in a short time
- Many empty food wrappers/container in room
- Hiding food and
- Hiding evidence of binge eating
Those are the symptoms specific to the most commonly diagnosed eating disorders. The other two – other specified feeding and eating disorder (OSFED) and avoidant/restrictive eating disorder (ARFID) – include many of the same symptoms. People with OSFED often engage in binging and purging at subclinical levels, combined with other symptoms such as extreme exercise, dieting, and connecting self-esteem to body image. People with ARFID, on the other hand, may show extreme weight loss and gradually restrict the foods they’re willing to eat, but do not fear gaining weight and do not experience disruption in body image/self-esteem/self-concept.
Prevalence of Eating Disorders
Data from the National Eating Disorders Association (NEDA) shows the following prevalence rates for anorexia, bulimia, and binge eating disorder:
- Anorexia:
- Females: 0.9% – 2.0%
- Males: 0.1% – 0.3%
Between 1.1% and 3.0% of adolescent girls report subclinical anorexia
- Bulimia:
- Females: 1.0%
- Males: 0.1%
Between 2.0% and 5.4% of adolescent girls report subclinical bulimia
- Binge eating disorder:
- Females: 0.2% – 3.5%
- Males: 0.9% – 2.0%
1.6% of adolescent girls report subclinical binge eating disorder
It may help to think those percentages in real numbers. For instance, the total population of females in the U.S. is around 143 million, while the total population of males is around 139 million. That means as many as 2.8 million females have anorexia at any given time, close to 20,000 men have bulimia at any given time, and as many as 50 million females have binge eating disorder at any given time.
Here’s another fact: close to 30 percent of clinically diagnosed eating disorders are treatment-resistant, which means they don’t respond well to a typical treatment protocol for eating disorders, which typically includes:
- Psychotherapy: Cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), and acceptance and commitment therapy (ACT)
- Family therapy
- Nutritional counseling
- Medical monitoring
- Psychiatric monitoring
- Support that addresses personal, family, and cultural issues related to the diagnosis
That’s what makes the study we discuss at the beginning of this article important. The 30 percent of people who don’t respond to traditional treatment may respond to an innovative brain stimulation therapy called transcranial magnetic stimulation (TMS).
TMS for Eating Disorders: The Evidence
Transcranial magnetic stimulation (TMS) is a safe, non-invasive treatment that’s approved by the Food and Drug Administration (FDA) for treatment-resistant depression, obsessive-compulsive disorder, smoking cessation, and migraine headaches. Compared to traditional treatments, TMS has several advantages:
- TMS acts quickly
- It’s non-invasive
- It does not require medication
- It has no systemic side effects
- Treatment can occur in outpatient or inpatient settings
These benefits – and the nature of TMS itself – led to the research on TMS for eating disorders that we’re sharing in this article. Before we get to the data, it’s important to understand that TMS is not like typical mental health treatment. TMS uses new technology to stimulate the brain with mild electromagnetic pulses directed at brain areas associated with mental health/addiction disorders. A clinician places a small electromagnetic coil or cap on the patient’s head and activates the pulses. Each treatment session lasts about 20 minutes, and patients typically engage in 2-3 sessions per week for 4-6 weeks.
TMS is safe and non-invasive, but more importantly – it works. Evidence already shows it’s appropriate for depression and other mental health disorders. Two recent publications – “The Status of Neuromodulation Trials in Eating Disorders” and “Repetitive Transcranial Magnetic Stimulation Strategies in the Treatment of Anorexia Nervosa: A Literature Review” – offer the latest evidence on TMS for eating disorders. Both these studies are considered meta-analyses, which means researchers gather all the reliable studies on a specific topic – TMS for eating disorders, in these studies – and report on trends identified after rigorous statistical analysis. Links for the studies we mention below appear in the references sections of the two studies we introduce above.
Results from Clinical Trials: TMS for Eating Disorders
Anorexia nervosa (AN):
One study of TMS for severe, treatment-resistant anorexia nervosa (AN) showed the following:
- At four months post-TMS treatment, researchers observed:
- Overall willingness to make eat more food
- Decreases in self-imposed food restriction
- Increased selection of tasty yet unhealthy foods
- This is a positive outcome for people with AN
- At 18-month post-TMS treatment, researchers observed
- Patient weight recovered to a body mass index (BMI) of 18.5 or greater, which is in the healthy range
- Patients with very low BMI at baseline did not respond well to treatment:
- Nutritional rehabilitation may need to precede treatment with TMS for people with AN with extremely low BMI
Another study of TMS for AN showed:
- Patients with AN showed improvements in the following areas:
- Mood: decrease in negative emotional states
- Quality of life: increase in positive days/frequency of positive emotional states
Bulimia nervosa (BN)
- One study showed that 20-30 TMS sessions showed increased blood flow to cortical regions associated with improved clinical BN outcomes
- In three random-controlled trials, patients with bulimia showed improvement in food cravings, compared to sham treatment/placebo
- One study showed TMS was associated with reduced urge to eat and reduced bulimia-associated binge eating
Binge eating disorder (BED)
- Several studies show TMS reduces food cravings and binge eating episodes
- A study of 28 people with BED showed TMS reduced binge/purge by at 50%
- Several single case studies show TMS reduces binge/purge behavior in people diagnosed with BED
Those results indicate that TMS is a promising treatment for the most common eating disorders. Patients with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) all showed improvement. However, researchers urge caution in using TMS in anorexia patients with extremely low BMI, because they did not respond as well to treatment as patients with higher baseline BMI. In addition, the consensus among researchers is that while TMS is safe, well-tolerated, and effective, more clinical trials are needed to establish ideal protocols that help patients achieve optimal treatment effectiveness.
On that subject, there is good news. We’ve identified at least three trials currently in process: one is for TMS for anorexia, one is for TMS for binge eating disorder, and one is for TMS for both anorexia and bulimia.
When we learn the results, we’ll share them, because the consequences of an untreated eating disorder can be severe. We’ll now discuss the risks of allowing an eating disorder to go untreated, and close this article with a list of important things to know about eating disorders provided by the National Eating Disorders Association (NEDA).
The Consequences of Untreated Eating Disorders
When we think of the real numbers, the statistics have meaning. They mean more when we consider the consequences of allowing an eating disorder to continue without treatment and support. The negative consequences of untreated eating disorders include:
Cardiovascular problems (heart and lungs):
- In absence of sufficient calories, the body breaks down muscle first, beginning with the heart muscle, which results in lowered blood pressure and pulse rate
- Purging depletes electrolytes, which are essential for heart health
- To conserve energy, the body’s resting metabolic rate decreases
Gastrointestinal problems (stomach and intestines):
- Nausea
- Vomiting
- Infections
- Perforation or rupture of stomach and/or intestines, both of which are considered life-threatening medical emergencies
- Constipation
- Pancreatitis caused by malnutrition
- Excess vomiting can cause perforation or rupture of the esophagus, considered a life-threatening emergency
Neurological (brain and nervous system):
- Chronic malnutrition/under-nutrition can cause cognitive impairment
- Extreme hunger or extreme fullness can cause insomnia
- Electrolyte depletion impairs proper firing of neurons (brain cells)
- Inadequate fat intake damages the protective layer of lipids (fat cells) around neurons, impairing function
Endocrine (hormones):
- Malnutrition can deplete the sex hormones estrogen and testosterone
- Malnutrition can deplete thyroid hormones
- Decreased levels of sex hormones can lead to osteopenia and osteoporosis, which are associated with increased breaks and fractures
- Malnutrition can lead to insulin resistance and type 2 diabetes
Those negative consequences are what make TMS an important new development in eating disorder treatment. For many people with chronic, treatment-resistant eating disorders, the hope of healing may have faded. TMS offers a possible life-changing solution, and relief when relief may have been hard to find.
We’ll end this article with a list from the National Eating Disorders Association (NEDA) called “9 Truths About Eating Disorders.” Please pay special attention to truth #9 – and if you think you or someone you love has an eating disorder, arrange a full evaluation from a mental health professional as soon as possible. Treatment can work – but requires an accurate diagnosis.
Nine Truths About Eating Disorders
- Many people with eating disorders look healthy, yet may be extremely ill.
- Families are not to blame, and can be the patients’ and providers’ best allies in treatment.
- An eating disorder diagnosis is a health crisis that disrupts personal and family functioning.
- Eating disorders are not choices, but serious biologically influenced illnesses.
- Eating disorders affect people of all genders, ages, races, ethnicities, body shapes and weights, sexual orientations, and socioeconomic statuses.
- Eating disorders carry an increased risk for both suicide and medical complications.
- Genes and environment play important roles in the development of eating disorders.
- Genes alone do not predict who will develop eating disorders.
- Full recovery from an eating disorder is possible. Early detection and intervention are important.